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HX64121682 
RC261  .B162  The  cancer  problem/ 


RECAP 


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THE    CANCER 
PROBLEM 


THE  MACMILLAN  COMPANY 

NBW  YORK  •    BOSTON   •    CHICAGO 
DAIXAS   •    ATLANTA    •    SAN  FRANCISCO 

MACMILLAN  &  CO.,  Limited 

LONDON   •    BOMBAY   •    CALCUTTA 
MELBOURNE 

THE  MACMILLAN  CO.  OF  CANADA;  Lnii 

TORONTO 


THE    CANCER 
PROBLEM 


BY 

WILLIAM   SEAMAN  BAINBRIDGE 
A.M.,  Sc.D.,  M.D 

IBOFES80B   OF  SURGERY,    NEW   YORK     POLYCLINIC    MEDICAL   SCHOOL  AND  HOSPITAL;     BURGEON,   ANI 

8ECRETABT  OP  COMMITTEE  OF  SCIENTIFIC  RESEARCH,  NEW  YORK  SKIN  AND  CANCER  HOSPITAL; 

CONSULTING   SURGEON,   MANHATTAN   STATE   HOSPITAL,  WARd's   ISLAND;   HONORARY 

PRESIDENT,   FIRST   INTERNATIONAL  CONGRESS   FOR   THE  STUDY   OF 

TUMOKS   AND   CANCERS,  HEIDELBERG,    I906 


^to  |9orfe 
THE  MACMILLAN  COMPANY 

1918 


Copyright,  1914 
B«  THE  MACMELLAN  COMPANY 


Set  up  and  electrotyped      Published  October,   1914. 
Reprinted  September,    1915. 


The  host  of  patient  sufferers  who  are  facing  pain  and 
death  from  cancer;  to  the  men  and  women  who  are 
earnestly  striving  to  discover  the  cause  and  cure  of 
the  disease;  to  the  noble  friends  of  humanity  who  are 
generously  aiding  in  this  struggle,  this  effort  to  gain 
light  upon  the  cancer  problem  is  dedicated. 


PREFACE 

The  cancer  problem,  as  it  exists  to-day,  has  a  much  greater 
significance  than  that  with  which  the  disease  itself  was  invested 
by  those  who  first  fancied  a  similarity  between  its  local 
manifestation,  the  tumor,  with  its  "roots,"  and  the  crab,  with 
its  claws,  and  who  applied  to  it  the  term  "cancer,"  or  "crab." 

These  ancients  who  studied  the  disease  had  no  conception  of 
its  prospective  importance  as  a  problem  of  far-reaching  im- 
port to  the  human  race.  The  deaths  from  cancer  to-day  are 
said  to  number  at  least  half  a  million  annually  among  civilized 
peoples  alone.  It  is  also  asserted  that  the  disease  is  increasing 
with  alarming  rapidity,  and  affecting  ever  younger  and  younger 
ages.  If  these  things  be  true,  then  we  have  here  a  problem 
which,  if  not  solved,  bids  fair  to  exterminate  mankind  as  effec- 
tually as  some  earlier  catastrophe  wiped  out  the  flying  reptilian 
monsters  whose  fossil  remains  afford  so  much  interesting  food 
for  speculation  to-day.  Even  if,  as  is  certain,  this  is  too  grave 
a  prospect,  cancer  is  nevertheless  the  one  major  problem  of 
medicine  still  defying  any  real  approach  to  solution,  as  regards 
prevention,  reliable  early  diagnosis,  or  guaranty  of  permanent 
cure. 

The  tumor  was  thought  by  early  observers  to  be  the  manifest 
effect  arising  from  the  "roots"  in  the  body  because  of  some 
constitutional  condition.  To-day  we  know  that  the  exact  oppo- 
site is  true.  The  tumor  is  the  starting  place,  and  its  "roots" 
are  the  offshoots  by  which  it  sends  out  "runners"  to  the  con- 
tiguous territory,  extending  further  and  further,  by  minute  or 
by  manifest  passages,  far  beyond  the  original  confines,  until 
the  whole  body  is  invaded. 

So,  to-day,  interest  in  the  "cancer  problem"  has  carried  it, 
by  one  kind  of  "runner"  or  another,  into  every  phase  of  life. 
ISTot  only  is  it  a  topic  for  discussion  in  the  operating  room  and 
the  medical  convention,  but  in  the  home,  in  the  business  office, 
in  the  lecture  room,  and  in  the  hall  of  legislation.  "Is  it  con- 
tagious?" "May  it  be  inherited?"  "Is  it  caused  by  certain 
kinds  of  food  ?"  "Is  it  influenced  by  environment  ?"  "Can  it 
be  prevented?"     "Can  it  be  cured?"     These,  and  many  more 


vi  PREFACE 

pointed  questions,  are  being  asked  by  laymen  as  well  as  by  the 
profession.  How  best  to  answer  them,  in  the  light  of  our  pres- 
ent knowledge  concerning  cancer,  is  a  debatable  matter. 

Much  of  the  mystery  which  surrounds  cancer,  much  of  the 
ignorance  concerning  it,  both  within  and  without  the  medical 
profession,  is  due  to  the  chaotic  condition  of  the  literature  upon 
the  subject.  To  acquire  dependable  information  concerning 
any  phase  of  the  question  entails  tedious  search  through  many 
books,  pamphlets  and  periodicals.  To  give  a  clear,  concise, 
comprehensive,  and  available  resume  of  the  world's  work  with 
reference  to  cancer,  its  history,  distribution,  etiology,  diag- 
nosis, possibility  of  prevention,  and  treatment,  together  with 
various  minor  matters,  is  a  most  difficult  task. 

With  the  development  of  the  widespread  interest  in  cancer 
there  has  arisen  a  definite  need  for  a  book  of  ready  reference, 
of  convenient  size,  giving  in  succinct  and  available  form  a  svim- 
mary  of  knowledge  concerning  the  subject.  This  is  needed  by 
the  general  practitioner,  by  the  specialist,  by  the  intelligent 
layman,  by  the  lecturer  on  health  matters;  in  fact,  by  all  who 
are  definitely  interested  in  questions  of  health  maintenance. 

In  attempting  to  meet  this  need,  at  least  in  part,  the  magni- 
tude of  the  undertaking  has  been  more  and  more  fully  realized 
as  the  work  of  collecting  and  formulating  the  data  has  pro- 
ceeded. It  has  been  necessary  to  touch  upon  practically  every 
phase  of  the  cancer  problem,  to  state  theories^  to  emphasize 
fadSj  to  review  the  work  and  opinions  of  those  who  are  qual- 
ified to  speak  with  authority,  and  to  maintain  throughout  an 
attitude  of  "suspended  judgment  pending  proof." 

In  addition  to  this  brief  consideration  of  the  essentials  of 
cancer  lore,  a  bibliography  of  some  of  the  most  important  con- 
tributions of  others  has  been  compiled,  in  order  that  the  reader 
who  desires  to  continue  the  study  of  cancer  in  greater  detail 
may  do  so  with  increased  facility  and  lessened  expenditure  of 
time.  Pictures  which  depict  the  horrors  of  cancer  are  pur- 
posely omitted. 

ISTo  attempt  is  made  to  give  a  complete  work  on  the  surgical 
treatment  of  malignant  neoplasms.  It  is  manifestly  impossi- 
ble, in  a  volume  of  the  size  and  scope  of  this  book,  to  cover  the 
entire  field.  At  a  later  date  perhaps,  a  second  volume,  or  a 
second  edition  of  the  present  volume,  may  be  put  forth,  giving 
a  thorough  digest  of  surgical  technic  as  applied  to  cancer. 

The  many  difficulties  of  the  task  which  this  volume  repre- 
sents will  be  most  keenly  appreciated  by  those  who  are  familiar 
with  cancer  research,  whether  in  the  laboratory,  in  the  operat- 
ing room,  or  at  the  bedside.     To  the  host  of  coworkers  in  this 


PREFACE  vii 

field  who  have  generously  given  their  encouragement  and  ad- 
vice I  extend  my  sincere  thanks.  To  members  of  my  staff  at 
the  New  York  Skin  and  Cancer  Hospital  I  am  indebted  for 
patient  assistance.  Particularly  do  I  desire  to  express  appre- 
ciation to  Dr.  J.  Douglas  Malcolm  for  the  careful  searching  of 
records  at  the  hospital  for  necessary  clinical  data ;  to  Dr.  D. 
Stuart  Dodge  Jessup  for  painstaking  pathological  work,  and 
to  Dr.  Worthington  Seton  Russell  for  assistance  in  the  electro- 
therapeutic  study  of  cases.  To  Dr.  Loy  McAfee  I  am  indebted 
for  valuable  assistance  in  the  arrangement  of  the  subject  mat- 
ter, especially  for  the  bibliography  and  index.  To  the  pub- 
lishers for  their  prompt  and  efficient  execution  of  their  part  of 
the  work  I  wish  to  express  my  sincere  thanks. 

The  mystery  which  to-day  obscures  the  essential  cause  of 
cancer  may  be  cleared  away  to-morrow ;  the  views  held  at  pres- 
ent may  of  necessity  be  abandoned  in  the  near  future.  Until 
such  a  fortunate  contingent  arises,  it  is  sincerely  hoped  that 
this  contribution  to  cancer  literature  may  be  of  interest  and 
profit  to  many  who  are,  or  who  may  desire  to  become,  students 
of  one  of  the  most  important  questions  of  modern  medicine — 
the  Cancer  Problem. 


CONTENTS 

SECTION    I 
History 

PAGE 

Ancient  History 1 

History  of  Modern  Cancer  Eesearch 4 

Influence  of  the  Campaign  Against  Tuberculosis         ...  4 
New  York  the  First  to   Establish   a  State  Institution  Devoted 

Exclusively  to  the  Study  of  Malignant  Disease     ...  .5 

Cancer  Commission  of  Harvard  University  .....  6 

Cancer  Eesearch  in  Germany         .......  7 

International  Association  for  Cancer  Eesearch  ....  8 

Cancer  Eesearch  in  England         .         .         .         .         .         .         .11 

Cancer  Eesearch  Laboratories,  Middlesex  Hospital   (London)     .  13 

Imperial  Cancer  Eesearch  Fund 16 

Other  Cancer   Eesearch   Institutions     ......  25 

Comparison  of  Methods  of  Investigation       .         .         .         .         .28 

Institutions  which  Combine  Clinical  and  Experimental  Work     .  29 

Eesearch  Department,  New  York  Skin  and  Cancer  Hospital     .  29 
Possibilities  of  Clinical  and  Experimental  Work  and  the  Utility 

of  Combining  or  Separating  Them 32 

Sunamary 36 

SECTION  II 

GENERAii  Distribution 

Introduction 37 

Chapter  I.    Botanical  Distribution 40 

Summary  .         .         .         .         .         .        .        .         .         .         .45 

Chapter  II.     Zoological  Distribution 47 

Influence  of  Environmental  Changes,  Including  Diet  .         .         .47 
Influence  of  Chemical  and  Other  Irritants  .         ,         .         .         .48 

Influence  of  Heredity 48 

Age  Incidence          ..........  49 

Influence  of  Use  on  Organs — Site  Incidence  .         .         .         .50 

Cancer  in: 

Dog 50 

Cat 51 

Horse        .         .  > 51 

Bovines     ...........  52 

Swine,  Sheep,  and  Goats 52 

Wild  Animals  in  Their   Native   State   and  in  Captivity     .  52 

Birds    (Domesticated  Fowl) 54 

Wild   Birds 54 

Eeptiles  and  Amphibians 54 

Fish 55 

MoUusks 58 

Summary           ..........  59 

ix 


X  CONTENTS 

PAGE 

Chapter  III.     Geographical  and  Ethnological  Distribution  .         .     60 
Influence  of  Climate,  Soil,  Diet,  and  Habits  of  Life  .         .         ,60 

i-Jaeial    Immunity •       .         .         .         .62 

Influence  of  Environmental  Changes  in  the  Production  of  Cancer     63 
illustrations   of    the   Universality   of    Cancer        .         .         .         .66 

India 66 

Gilbert  Islands 68 

Iceland 68 

Summary 69 

SECTION  III 

Statistical    Considerations 

Significance  and  Value  of  Statistical  Studies 70 

Difficulties  Encountered  in  the  Collection  of  Statistics  ,  .  71 
Universality  of  Cancer,  as  Shown  by  Statistical  Studies  .  .  72 
Possible  Errors  in  the  Compilation  of  Statistics  .  .  .  .72 
Fallacies  of  American  Methods  of  Compiling  Statistics  .  .  73 
Importance  of  Autopsies  in  the  Compilation  of  Cancer  Statistics  76 
Factors  to  Be  Considered  in  Calculating  Cancer  Death-rate 
Occupational  Mortality  from  Cancer 

Is  Cancer  Increasing? 

Cancer  Mortality  According  to  Locality  . 
Relation  of  Statistics  to  Etiology     . 
Summary 


80 
82 
90 
91 
104 


SECTION  rv 

Etiology 

Chapter  I.     Theories 106 

Early  Theories 106 

Theories  Which  Have  Engaged  Attention  Since  the  Beginning 

of  Modern  Cancer  Research 108 

Biological    Theories 108 

Intuence  of  Humoral  Theory  Upon  the  Scientific  Study 

of  Cancer ".  108 

Virehow's  Theory Ill 

Thiersch's   Theory Ill 

Waldeyer's  Theory 112 

Cohnheim's   Theory 113 

Ribbert's   Theory 114 

Hauser  's    Theory 115 

Other   Theories 116 

Parasitic  Theories 117 

Summary 121 

Chapter  II.     Predisposing  Causes 122 

Bearing  of  Experimental  Investigation  upon  Existent  Theories  122 

Atreptic   Theory    (Ehrlich) 124 

Chronic  Irritation  .........  126 

Precancerous  Conditions 127 


CONTENTS  xi 

PAGE 

Environment  ..........  127 

Diet 128 

Summary         ...........  128 

SECTION  V 

HiSTOPATHOLOGY 

Definition 130 

Value  of  Histological  Study      .        .        .        .        .        .        .        .  132 

Histological  Appearances 134 

Classification 137 

Origin  and  Spread 140 

Basis  of  Surgical  Treatment 141 

Summary 142 

SECTION  VI 

Cancer  Eesearch — A  E^sume  of  the  World's  Work 

Practical  Eesults 144 

Failure  of  Modern  Experimental  Study  of  Cancer  to  Establish 

the  Etiology  of  the  Disease  .......  144 

"Individuality"  of  Cancer  Established  by   Experiment     .         .   147 
Possibility  of  Transference  no  Proof  of  Infectivity  of   Cancer  148 
' '  Limitless ' '   Growth   of   Cancer   .......  149 

Bearing  of  the  Study  of  Propagation  upon  Other  Phases  of  the 

Cancer  Problem       .........  150 

Microscopical    Demonstration    of    the    Facts    of    Transferring 

Cancer      ...........  150 

Propagation    Experiments    Justify    the    Surgical    Treatment    of 

Cancer      ...........  151 

Infectivity  of  Cancer  in  the  Light  of  Propagation  Experiments  151 

Theoretical  Eesults 154 

Criticism  of  the  Value  of  Propagation  ......  154 

Criticism  of  the  Value  of  Prolonged  Propagation         .         .         .  158 

Bearing  of  Immunity  Eeactions  and  op  Propagation  on  the  Na- 
ture OF  Cancer 161 

Constancy  and  Variability  of  Tumor  Cells 162 

Constancy  and  Variability  of  Histological  Structure  .         .         .  162 
Constancy  and  Variability  of  More  Subtle  Properties  .         .         .  163 
Sarcoma   Development    .........  164 

Immunity  Eeactions       .........  165 

Eesistance   to   Heterologous   Inoculation 166 

Heterologous  Immune  Sera  .         .         .         .         .         .         .         .  167 

Homologous  Immunization  and  Eesistance  .....  167 

Natural  Eesistance 167 

Active  Eesistance  Induced  by  Tumors 168 

Active  Eesistance  Induced  by  Normal  Tissue     ....  169 

Parallel  in  the  Onset,  Duration,  and  Distribution  of  the  Eesist- 
ance Induced  by  Tumor  and  Normal  Tissue         .         .         .  170 
Distinction   between  Living  and  Dead   Tissues   ....  171 

Homologous  Immune  Sera     ........  171 

Nature  of  the  Change 171 


xii  CONTENTS 

PAGE 
Spontaneous  Healing  .  .  .  .  ,  .  .  ,  .172 
Examination  of  the  Site  of  Grafting  ......  172 

Eeaction  Throughout  the  Body 173 

Eelative  Weights  of  the  Several  Organs       .         .         .         .         .173 

Auto-  or  Concomitant  Resistance  .         .         .         .         .         .         .174 

Autologous  Inoculations         ........  175 

Loss  of  Power  to  Induce  Resistance  and  Acquisition  of  Powers 

of    Continuous   Growth 175 

Hypersensitiveness  .         .         .         .         .         .         .         .         .176 

Possibility  of  Applying  Results  to  Explain  Nature  of  Cancer     .  176 

Summary 177 


SECTION  VII 

Clinical  Course;  Diagnosis;  Possible  Errors  in  Diagnosis 

Chapter  I.    Clinical  Course 180 

Summary 187 

Chapter    II.     Diagnosis 188 

Clinical 188 

Microscopic 190 

Serodiagnosis  ..........  191 

Summary         ...........  194 

Chapter   III.     Possible  Errors   in   Diagnosis 195 

Head 196 

Tongue 199 

Breast 201 

Abdomen 204 

Pelvic   Organs 216 

Summary 219 

SECTION  VIII 

Prophylaxis 
Introduction 220 

Environment  (Diet,  Hygiene,  Occupation,  Etc.)       ....  221 

Precancerous   Conditions 222 

Local  Manifestations  op  Other  Diseases 224 

Sources  of  Chronic  Inflammation  and  Irritation  ....  225 

Case  Reports 228 

Summary 235 

SECTION  IX 
The  Investigation  op  "Cancer  Cures" 

Diversity  of  Agents  Employed  in  the  Treatment  op  Cancer  .        .237 

What  the  Surgeon  Has  a  Right  to  Know  op  a  Proposed  Method 

OF   Treatment 239 

What  Constitutes  a  "Fair  Test" 241 


CONTENTS  xiiL 

PAGE 

The  Enzyme  Treatment  (Trypsin  and  Amylopsin,  Plus  R^&gime)  242 

Serum  from  Birds  of  Prey 251 

"  Canckoidin,  "   " Antimeristem  "    (Otto  Schmidt   Serum   oe  Vac- 
cine)        252 

Doyen's  Serum 256 

Chian   Turpentine    (Pistacia   Terebinthus) 257 

Sodium  Oleate   (Soap  Solution)   and  Ox-gall  .        .        .        .        .  258 

Molasses 259 

Violet  Leaves 260 

Investigation  op  "Quack  Cures" 261 

Mattei  "Electricities"        .        .        .        .        .        .        .        .        .  261 

Cardigan  (Wales)  "Cancer  Curers" 268 

"^siAB  Cancer  Cure" 270 

Davis  Cancer  "Cure"   (Melbourne,  Australia)       .        .        .      •  ,  271 

Summary 276 

SECTION  X 

NON-SUBGICAL     TREATMENT 

Chapter  I.     Caustics  or  Eschaeotics 277 

Summary 286 

Chapter   II.    Physiotherapy 287 

Heat 287 

Light 288; 

Sunlight 288 

Electricity 289 

Arc   Light 289 

Incandescent  Light  ........  290 

Fluorescent   Stimulation 291 

X-Rays 291 

Eadio-activity 297 

Eadium 297 

Mesothorium 304 

Radio-active   Gelatin 305 

Electrocautery    (Byrne  Method) 306 

High-frequency   Current  .         .         .         .         .         .         .         .308 

Alto-frequent  Cytolysis,  Alto-frequent  Scintillation,  EflSeuvation, 

Etc.    (Riviere) 309 

"Destructive   Fulguration" 310 

Fulguration    (de   Keating-Hart) 310 

Surgical  Technic     .         .         .         .         .         .         .         ,         .314 

Electrical  Technic 314 

Theoretical  Basis  of  Fulguration 316 

Thermopenetration    (d'Arsonval) 316 

Thermoradiotherapy   (de  Keating-Hart) 317 

Diathermy,  or  Transthermy   (Nagelsehmidt)         ....  320 

Electrocoagulation    (Doyen) 321 

Bipolar  Voltaization    (Doyen) 322 

Oscillatory   Desiccation    (Clark) 322 

Ionic   Surgery    (Cataphoresis) 323 

Summary 324 


CONTENTS 


PAGE 

Chapter  ITT.     Biotherapy 327 


Classification  of  Agents         ..... 
Definition  of  Terms       ...... 

Antitoxin;   Antitoxic  Serum;    Bacterial  Toxins 

Residues;    Extracts;    Emulsions 

Sierous  Exudates  and   Body   Fluids   (Sera)    . 

Opotherapcutic    Measures    (organotherapy)    . 

A.  Based  on  Bacteriology    ..... 
Sera   (Bacterial  Toxins)  .... 

B.  Based  on  Cytolysins  or  Cytotoxins 
Vaccines  ........ 

Residues;  Extracts;  Emulsions 

Serous  Exudates  and  Body  Fluids   (Sera) 
Opotherapcutic   Measures        .... 
Summary  ........ 


.  327 
.  328 
.  329 
.  330 
.  330 
.  331 
.  332 
.  332 
.  338 
.  338 
.  338 
.  341 
.  343 
.  343 


SECTION"    XI 

Surgical  Treatment 

Chapter  I.  General  Techntc  of  Surgery,  as  Applied  to  Cancer  .  345 
Purposes  of  Surgical  Treatment  of  Cancer  .....  353 
Summary         ...........  355 

Chapter  II.     Special  Technic 356 

A.  Surgical  Technic  Based  upon  the  "Permeation  Theory"  of 

Cancer    Dissemination      .......  356 

Modified  Operation  for  Cancer  of  the  Breast         .         .         .  362 
Permeation  Theory  Applicable  to  Other  Localities       .         ,  364 
"  Operability "  of  Cancer  of  Rectum  Extended  by  Permea- 
tion Theory .         .365 

Permeation  Theory  Applicable  to  Melanotic  Sarcoma  .         -   367 

B.  Plastic  Procedures 368 

C.  Palliative  Measures 369 

Nervous  System 369 

Neurectomy       .........  369 

Decompressive   or   Decompression   Operations         .         .   369 
Lymphatic  System  .         .         .         .         .         .         .         .         .370 

Lymphangioplasty    ........  370 

Paracentesis  Abdominalis         ......  371 

Thoracocentesis         ........  371 

Vascular  System 372 

"Starvation   Ligature" 372 

History 372 

Ligation  and  Exsection  of  External  Carotid  Artery 
(Dawbarn  Method)   in  the  Treatment  of  Ma- 
lignant Tumors  of  the  Head  and  Face  .         .  374 
Technic  of  Carotid  Excision  and  Injection  of  the 

Two   Terminal  Branches   .....  376 

Indications  for  the  Operation 379 

Table  of  Cases 381 

** Starvation  Ligature,"  with  Lymphatic  Block,  in  the 
Treatment  of  Advanced  Cancer  of  the  Pelvic 
Organs        ........  383 

History 383 

Purposes  of  the  Method 386 

Objections  Which  May  Be  Raised  Against  the  Pro- 
cedure        ........  389 

Indications         ........  390 

Technic 391 


CONTENTS  XV 

PAGE 


^.Q"? 


Special  Points  of  Technie  to  Be  Observed 

Clinical  Application 394 

Table  of   Cases 396 

E«spiratory  System 412 

Tracheostomy  ........  412 

Alimentary  System  ........  412 

Esophagostomy  ...  ....  412 

Gastrostomy 412 

Gastroenterostomy  .         .  ....  412 

Colostomy 412 

"Short-circuit" 413 

Colectomy  .........  413 

Urinary   System      .........  413 

Cystostomy 413 

Nephrotomy      .........  413 

Ureteral   Transplantation 413 

Biliary  System 414 

Cholecystostomy 414 

Summary         .         .         .         ..         .         .        .        .         «         .  414 


SECTION  XII 

Irremovable  Cancer 

Introductory  Eemarks 415 

Seemingly  Irremovable  .        .        . 418 

Operable,  but  Irremovable,  yet  Curable 420 

Operable,  but  Irremovable  and  Incurable 421 

Treatment  of  Conditions  Caused  by  or  Complicating  Cancer     .  421 
Treatment  of  the  Cancer  per  se     ......         .  422 

Treatment  of  the  Patient      ........  422 

Inoperable,  Irremovable,  Incurable 422 

Institutional  Care 423 

Mental  Condition 423 

Physical  Condition 425 

Diet 426 

Pain 427 

Care  of  Ulcerating  Surfaces  and  Fungating  Masses     .         .         .  427 

Summary .        .        .        .  428 


SECTION   XIII 
Institutions  for  the  Care  of  Cancer  Patients 

Introductory  Eemarks 429 

In  Europe 429 

In  America 431 

Almshouse  Hospital  (New  York  City) 432 

City  Hospital   (New  York  City) 432 

General  Memorial  Hospital  (New  York  City)       ....  432 
New  York  Skin  and  Cancer  Hospital  .         .         .         ...         .  432 

Private  Institutions •        .  432 


xvi  CONTENTS 

PAGE 

Benevolent  Institutions 432 

Fordham  Home  for  Incurables  (New  York  City)  .         .         .  432 

House  of  Calvary  (New  York  City) 433 

St.  Eose's  Free  Home  for  Incurable  Cancer  (New  York  City)     .  433 

"Quack"  Cancer  Institutions 433 

The  Lot  op  the  Patient  at  Home 434 

Need  for  Adequate  Facilities 435 

Summary 436 

SECTION  XIV 
The  Campaign  of  Education 

Introductory  Eemarks 438 

The  Education  op  the  Medical  Profession 440 

The  Education  of  the  Public 445 

Need  the  Layman  Be  Educated? 445 

How  Best  to  Conduct  the  Campaign? 447 

Summary 451 

THE  OUTLOOK 452 

BIBLIOGRAPHY 455 

INDEX  OF  AUTHORS .  509 

INDEX 513 


PLATES 


Group  of  Natives  of  Kashmir  with  Kangri  Baskets      .      Frontispiece 

PIATB                                                                                                                                                                               FACING  PAGE 

I.     Kangri   basket .         .67 

II.     Group  of  natives  of  Kashmir  with  Kangri  Baskets  67 

III.  Epithelial  wart  from  wrist  of  a  worker  in  paraffin 

distillation 126 

IV.  Early  squamous-eelled  carcinoma  of  tongue,  natural 

size  and  magnified  fifty  times         ....  134 

V.     Carcinoma    (scirrhus)   of  breast         ....  135 

VI.     Soft  or  medullary  carcinoma  of  breast         .         .         .  135 

VII.     Small  carcinoma  of  breast,  natural  size  and  magnifi- 
cation         135 

VIII.     Squamous-eelled  carcinoma  growing  in  lymph  gland  135 

IX.     Squamous-eelled  carcinoma  spreading  by  permeation 

of  a  lymphatic       .......  135 

X.     Ulcerating  adenocarcinoma  of  breast ....  135 

XI.     Spread  of  adenocarcinoma  of  breast  between  muscle 

and  inside  muscle  fibers         .....  135 

XII.     Adenocarcinoma  of  breast  growing  in  a  lymphatic 

gland 135 

XIII.  Invasion  of  a  long  bone  by  adenocarcinoma  of  the 

breast 135 

XIV.  Adenocarcinoma  of  rectum         .....  136 

XV.     Secondary    deposit    of    adenocarcinoma    of    rectum 

growing  in  liver       .         .         .         .         .         .         .136 

XVI.     Adenocarcinoma  of  rectum  spreading  by  the  blood- 
stream     .         o         .       ■  .         .         .         .         .         .  136 

XVII.     Secondary  deposit  of  adenocarcinoma  of  liver  grow- 
ing  in    lung 136 

XVIII.     Malignant    tumor    of    thyroid    gland         .         .         ,  136 

XIX.     Papilloma  of  skin 136 

XX.     Margin  of  squamous-eelled  carcinoma  of  tongue         .  138 

XXI.     Squamous-eelled  carcinoma  of  tongue  spreading  be- 
tween and  destroying  muscle  fibers         .         .         .  136 

XXII.     Deep  aspect  of  a  small  malignant  ulcer  of  tongue     .  136 

XXIII.     Margin  of  rodent  ulcer         ......  137 

xvii 


PLATES 


PLATB 

XXIV.     Paget's  disease 

XXV.     Small  roiuul-cellod  sarcoma 

XXVI.     Large  roiuul-cellcHl  sarcoma  showing  marked  tendency 
to  necrotic  des:oneration 

XXVII.  •  Spindle-eelled   sarcoma       .... 

XXVIII.     Melanotic  sarcoma  of  sole  of  foot  following  a  punc- 
ture       

XXIX.     Melanotic  sarcoma 

XXX.     Melanotic    sarcoma.      Secondai-y    in    liver,    showing 
fatty  degeneration  of  liver  cells     . 

XXXI.  Fibroma 

XXXII.  Fibroadenoma  of  breast       .... 

XXXIII.  Structure  of  subcutaneous  capillary  nevus 

XXXIV.  Mixed  tumor  of  parotid  region 

XXXV.  Choi-ion  epithelioma  of  uterus     . 

XXXVI.     High-power  view  of  failure  to  supply  the  specific 
scaffolding  on  the  part  of  an  immunized  rat 

XXXVII.  High-power  view  of  the  fonnation  of  new  blood 
vessel  and  stroma  scaffolding  for  a  graft  of  ear 
einoma  in  a  normal  rat         .... 

XXXVIII.     Illustrating  the  permeation  theory  of  Handley 


FACING     PAQB 

139 
139 


139 
139 


13fl 
139 

139 
130 
139 
139 
139 
139 

173 

173 
361 


LIST  OF  ILLUSTEATIONS  IN  THE  TEXT 

SECTION   III 

FIG.  PAGE 

1.  Map  showing  true  state  of  American  Vital  Statistics  in  1900      75 

2.  Map  of  McConnell 76 

3.  Chart  giving  analysis  of  cancer  for  women         .         ...         .84 

4.  Chart  giving  analysis  of  the  increase  of  cancer  for  men         .     85 

5.  Chart   indicating   diagrammatically   the   increase   in   the   age 

of   the   population    of    England   and   Wales         .         .         .89 

6.  Chart  giving  percentage  of  deaths  from  mammary  carcinoma     98 

7.  Chart   giving    death-rate  from   cancer    in  mice  of   cancerous 

ancestry 99 

SECTION  IV.     CHAPTER  I 

1.  Diagrammatic  representation  of  differentiation  of  somatic  and 

reproductive  tissues  in  higher  animals         ....     Ill 

2.  Diagram  of  hypothesis  of  Thiersch  and  Waldeyer         .         .  112 

3.  Diagram   of   Cohnheim's   hypothesis         .....  114 

4.  Diagram   of  Ribbert's  hypothesis 115 

5.  Diagram  of  hypothesis  of  "gametoid"  nature  of  cancer         .  117 

6.  Diagram  of  parasitic  hypothesis 118 

SECTION  VI 

1.     Curves  showing  extent  and  duration  of  induced  resistance  in 

mice 170 


THE    CANCER 
PROBLEM 


THE  CANCER   PROBLEM 


SECTION    I 

HISTORY 
ANCIENT   HISTORY 

Abundant  historical  references  lead  to  the  belief  that  the 
disease  which  we  now  designate  as  cancer  was  known  to  the 
ancients  at  least  two  thousand  years  ago.  They  worked  with- 
out lens  or  microscope,  and  hence  could  determine  nothing  con- 
cerning the  minute  structure  of  tumors  and  the  various  tissue 
manifestations  with  which  they  confused  cancer.  Undoubtedly 
many  errors  in  diagnosis  were  made,  and  many  diseases  now 
accepted  as  of  non-malignant  nature  were  considered  malignant 
by  earlier  observers,  just  as  leprosy,  which  is  so  familiar  to 
every  child  who  has  read  the  Bible,  probably  covered  many 
forms  of  ulcerating  sores  as  well  as  certain  scaly  skin  diseases, 
and  did  not  necessarily  mean  only  the  leprosy  of  which  we 
speak  to-day. 

It  is  not  to  be  wondered  at,  therefore,  that  imagination  was 
given  full  play  in  the  evolution  of  the  elaborate  theories  of 
etiology  which  have  marked  the  development  of  the  cancer 
problem,  as  in  almost  all  problems  of  disease,  from  insanity  to 
plague;  nor  is  it  surprising  that  the  therapeutic  history  of  the 
disease  is  one  of  the  most  fantastic  of  any  in  the  annals  of 
medicine  and  surgery. 

In  looking  back  over  the  records  of  the  past,  we  find  such  a 

diversity  of  opinions  regarding  the  origin  of  cancer,  that  to 

give   a  brief  catalogue   of  the  various  theories  would  be   an 

unnecessary  tax  upon  the  reader's  time  and  patience.     This  has 

been  done  in  a  very  full  and  able  manner  by  Wolff.  ^      The 

causative  factors  involved  range  from  the  three  "humors"  of 

Hippocrates,  Celsus,  and  Galen,  through  practically  all  the  indi- 

'  Wolff,   Jacob. — * '  Die  Lehre  von   der   Krebskrankheit  von   den   altesten. 
Zeiten  bis  zur  Gegerwart,"  Jena.    Vol.  I,  1907.    Vol.  II,  1911. 

1 


2  THE    CANCER    PROBLEM 

vidual  tissues  of  the  body;,  and  to  a  bewildering  number  and 
variety  of  extraneous  agencies.  Even  the  mysticism  of  the 
past  has  been  invoked  to  account  for  this  disease,  for  we  are 
told  by  van  Ilelmont  (1578-1644)  that  cancer  is  due  to  a 
spiritual  being,  the  Arcliwus,  in  the  stomach  and.  spleen,  which 
must  be  purified  and  thus  prevented  from  sending  its  ferments 
into  the  wrong  parts. 

The  earlier  theories  which  engaged  scientific  attention  are 
briefly  considered  under  the  subject  of  Etiology  (Section  IV, 
Chapter  I). 

Since  the  beginning  of  recorded  medical  history,  and  doubt- 
less long  before,  imagination  was  given  full  play  in  the  treat- 
ment of  cancer.  The  "witch  doctor"  combined  the  secrets  of 
the  "black  art"  with  the  brewing  of  the  "witch's  broth,"  and 
the  unfortunate  victim  of  cancer  was  given  doses  of  the  mix- 
ture. Throughout  the  centuries  the  sufferer  from  this  disease 
has  been  the  subject  of  almost  every  conceivable  form  of  experi- 
mentation. The  fields  and  forests,  the  apothecary  shop  and 
the  temple,  have  been  ransacked  for  some  successful  means  of 
relief  from  this  intractable  malady.  Hardly  any  animal  has 
escaped  making  its  contribution,  in  hair  or  hide,  tooth  or  toe- 
nail, thymus  or  thyroid,  liver  or  spleen,  in  the  vain  search  by 
man  for  a  means  of  relief.  The  hand  on  the  dial  has  turned 
many  times  to  the  same  point  of  effort  during  the  progress  of 
the  centuries,  and  it  is  possible  to  find  in  remote  districts 
to-day  the  same  remedies  being  used  that  were  employed  by 
"cancer  curers"  of  long  ago. 

We  are  told,  for  example,  that  the  idea  that  green  frogs  in 
some  way  influenced  the  course  of  cancer  has  prevailed  for 
hundreds  of  years,  and  still  prevails  in  certain  quarters. 
Bonet,  of  Geneva,  in  1682,  gave  a  prescription  for  an  ointment 
made  of  green  frogs.  In  the  "Kook-Koeck  en  Recepte  Boek," 
by  E.  J.  Dijkman,  published  in  Cape  Colony,  eighth  edition, 
1905,  occurs  the  following  interesting  item  (Trans.  J.  Muir)  : 
"An  example  of  a  woman  who  had  cancer  of  the  breast,  which 
was  already  so  severe  that  eight  holes  had  been  eaten  into  it,  and 
who  recovered  through  the  following  expedient :  She  took  eight 
frogs  applied  to  the  breast  in  a  muslin  bag,  which  attached  them- 
selves instantly  thereto  as  firmly  as  leeches.  When  they  had 
sucked  to  repletion,  they  dropped  off  in  violent  convulsions 
without  the  sucking  causing  pain.  This  was  repeated  until 
20  frogs  were  used,  which  all  from  time  to  time,  sucked  until 
they  died.  And  the  breast  was  not  only  cured,  but  returned 
again  to  its  normal  size  absolutely." 

Fabricius  Hildanus,  of  Hilden  near  Cologne   (1560-1634), 


HISTORY  S 

is  said  to  have  asserted  from  certain  experience  ^  that  the  fol- 
lowing is  admirable  in  curing  ''ulcerous  cankers."  The  receipt 
for  the  water  is  as  follows :  "Take  suckling  Puppies,  put  them 
in  Wine,  and  distill  it  half  off  in  Balneo ;  then  take  the  puppies 
out,  and  boil  them  in  a  sufficient  quantity  of  Golden-Rod  Water, 
or  common  Water  with  Golden-Rod  in  it ;  when  the  Decoction  is 
made,  add  the  Water  that  was  distilled  off  the  young  Dogs  and 
boil  them  together  till  the  flesh  comes  from  the  Bones.  Then 
distill  them  all  in  Balneo.  Keep  the  Water  for  use.  Wet  dry 
clothes  or  rags  in  this,  and  apply  it  to  the  ulcerous  carcinoma. 
For  from  certain  Experience  it  heals  the  sore  by  cleansing  and 
drying." 

The  liver  of  a  tortoise  "laid  on  the  cancer  and  used  con- 
tinuously" is  a  Cape  Colony  remedy  in  the  "Kook-Koeck  en 
Recepte  Boek." 

Plunket,  a  famous  "cancer  curer"  of  the  eighteenth  century 
in  England,  used  a  paste  of  crow's  feet,  dog  fennel,  sulphur, 
and  arsenic.  The  popularity  of  this  paste  is  said  to  have  suf- 
fered a  severe  setback  when,  according  to  report,  it  caused  the 
death  of  Lord  Bolingbroke  (Henry  St.  John  Vincent),  in  1751. 
Arsenic,  which  was  the  base  of  this,  as  well  as  of  many  other 
pastes,  continues  to  play  an  important  role  in  the  medical 
treatment  of  cancer. 

John  Muir,^  M.D.,  District  Surgeon,  Sterkstroom,  South 
Africa,  gives  an  interesting  account  of  the  various  "cures" 
and  "curers"  of  South  Africa.  Of  the  herbal  remedies  the 
best  known  is  the  "cancer  bush,"  or  "kanker  boschje,"  the 
Sutherlandia  frutescens  R.  Br.,  order  Leguminosae.  An  in- 
fusion is  made  of  the  bark  and  leaves,  and  a  cupful  of  this  is 
taken  three  times  a  day.  As  an  external  application,  the  oil 
which  accumulates  in  the  pipe  of  a  dagga  smoker  is  used  by 
the  inhabitants.  In  some  instances  cancer  was  claimed  to  have 
been  cured  in  three  days  by  this  "wonderful  remedy,"  which 
is  still  in  use  in  South  Africa. 

The  list  of  non-surgical  measures  which  have  been  employed 
in  the  treatment  of  cancer  embraces  hundreds  of  mineral,  vege- 
table, physical,  and  animal  products,  which  it  would  be  profit- 
less to  detail,  or  even  to  catalogue.  Many  of  these  are  con- 
sidered in  other  sections. 

The  history  of  the  surgical  treatment  of  cancer  assumed 
rational  proportions  at  a  much  earlier  date  than  did  the  non- 

* "  A  Medico-Literary  Causerie.  Cancer  Curers, ' '  Practitioner,  April, 
1899,   p.  518. 

^  Muir,  John. — ' '  The  Cancer  Curer  in  South  Africa, ' '  South  Africa 
Medical  Record,  January,   1906,  p.  5. 


4  THE    CANCER    PROBLEM 

surgical.  As  far  back  as  2000  B.C.,  in  the  writings  of  ancient 
India,  are  to  be  found  directions  for  the  removal  of  cancerous 
growths.  Kadical  excision  has  been  advocated  for  centuries, 
but  it  is  only  within  comparatively  recent  years,  or  since  sur- 
geons have  come  to  understand  the  histopathology  of  cancer, 
that  surgical  technic  has  developed  to  such  a  degree  of  perfec- 
tion as  to  enable  one  to  say  with  assurance  that  it  is  possible 
to  effect  a  cure  of  the  disease  by  means  of  surgical  intervention. 

It  has  been  said  that  more  has  been  accomplished  in  the 
study  of  cancer  during  the  past  fifteen  years,  or  since  the  initia- 
tion of  modern  cancer  research,  than  during  the  preceding  fif- 
teen hundred  years. 

Such  an  enormous  volume  of  literature  has  accumulated  on 
the  subject  of  the  origin,  development,  nature,  and  treatment  of 
cancer,  that  to  give  merely  a  chronological  review  of  the  history 
of  the  disease  would  fill  more  than  one  volume  of  this  size. 
We  must  content  ourselves,  therefore,  with  a  bibliography  of 
the  early  history,  devoting  more  detailed  consideration  to  that 
later  period  which  covers  the  era  of  scientific  cancer  research. 

HISTORY    OF    MODERN    CANCER    RESEARCH 

THE    INFLUENCE    UPON    CANCER    RESEARCH    OF    THE    CAMPAIGN 
AGAINST    TUBERCULOSIS 

The  renewed  activity  in  the  investigation  of  cancer,  which 
has  characterized  the  past  fifteen  years,  is  directly  traceable  to 
the  success  attendant  upon  the  organized  campaign  against 
tuberculosis.  This  campaign  was  initiated,  at  an  international 
conference  held  in  Berlin,  in  1902,  by  the  founding  of  the 
"International  Anti-tuberculosis  Association."  Since  that  time 
eleven  such  conferences  have  been  held. 

Inasmuch  as  the  cause  of  tuberculosis  was  known,  it  was 
possible  to  proceed  to  the  practical  work,  and  to  set  in  motion 
measures  for  the  suppression  or  prevention  of  that  disease. 
The  movement  speedily  spread  throughout  the  civilized  world. 
Nursing  homes,  originally  established  in  Belgium,  were  set  up 
also  in  France  and  Germany.  The  rapid  progress  of  the  cam- 
paign is  illustrated  by  the  fact  that  the  18  modest  hospitals  for 
tuberculous  out-patients  founded  in  Germany  in  1903,  paved 
the  way  for  the  819  nursing  institutions  existing  in  that  coun- 
try in  1913.  At  the  same  time  and  in  the  same  country  there 
were  147  sanatoria,  with  15,278  beds;  103  institutions  with 
more  than  9,000  beds  for  children  threatened  with  tubercu- 
losis; 114  forest  sanatoria,  and  17  forest  schools.     In  addition 


HISTORY  5 

to  all  this,  special  tuberculosis  wings — rather  than  sanatoria — 
were  provided  in  1913  in  connection  with  200  general  hos- 
pitals. 

The  great  success  of  the  movement  against  tuberculosis  has 
nowhere  been  more  strikingly  evident  than  in  New  York  City. 
It  is  not  within  the  scope  of  this  volume,  however,  to  dwell 
upon  the  success  of  the  tuberculosis  movement,  further  than  to 
show  how  it  preceded  the  revival  of  interest  in  the  cancer  prob- 
lem, and  how,  in  many  instances,  it  actually  determined  the 
nature  of  the  organization  and  the  machinery  with  which  a 
similar  campaign  against  the  latter  disease  was  inaugurated 
almost  simultaneously  in  America,  England,  and  Germany. 


NEW    YORK    THE    FIRST     TO    ESTABLISH    A    STATE    INSTITUTION 

DEVOTED    EXCLUSIVELY    TO    THE    STUDY    OF 

MALIGNANT    DISEASE 

In  America  the  inception  of  the  movement  for  the  study  of 
cancer  was  largely  due  to  the  late  Professor  Roswell  Park,^ 
who,  in  1899,  described  its  beginning  as  follows : 

"Lastly,  let  me  invite  special  attention  to  work  recently  done 
and  projected  in  ISTew  York  State.  Last  year,  as  the  result  of 
persistent  efforts  on  the  part  of  a  number  of  men — ^both  pro- 
fessional and  laymen,  both  in  and  out  of  the  legislature — the 
legislature  of  New  York  appropriated  a  small  sum  for  the 
purpose  of  'equipping  and  maintaining  a  laboratory'  devoted 
to  this  kind  of  research.  The  money  was  placed  at  the  disposal 
of  the  Medical  Department  of  the  University  of  Buffalo,  which 
seems  to  be  located  in  a  region  where  cancer  is  more  prevalent 
than  in  any  other  part  of  the  United  States.  The  laboratory 
was  at  once  instituted  and  put  into  operation,  the  writer  of 
this  paper  being  made  its  director;  and  the  pathological  work 
was  soon  placed  in  charge  of  Dr.  H.  R.  Gaylord.  The  equip- 
ment of  the  laboratory  is  of  the  very  best,  and  the  personnel 
of  its  working  staff  admirably  adapted  to  the  work  in  hand. 
The  primary  object  of  this  institution  is  a  determination,  if 
possible,  of  the  nature  of  the  disease;  secondary  to  that,  of 
course,  being  whatever  may  be  accomplished  for  its  medication 
and  cure.  The  heartiest  cooperation  of  the  profession  has  been 
publicly  invited,  and  already,  in  many  instances,  obtained. 
The  closest  relation  exists  between  the  laboratory  itself  and  the 
clinical  opportunities  which  the  University  affords,  so  that  by 
this  means  there  may  be  the  most  careful  study  carried  on  at 

1  Park,  Eoswell. — ' '  A  Further  Inquiry  into   the  Frequency  and   Nature 
of  Cancer,"  The  Practitioner,  Vol.  62,  April,  1899,  p.  385. 


6  THE    CANCER    PROBLEM 

the  same  time  of  the  patient  himself  and  of  the  specimen  re- 
moved. The  work,  so  far  as  projected,  inchidcs  everything 
that  may  he  done  in  the  way  of  clinical  study  of  cases,  espe- 
cially those  which  are  under  the  personal  observation  of  mem- 
bers of  the  laboratory  staff,  a  most  careful  study  of  the  patho- 
logical and  histological  elements  found  in  every  fresh  specimen 
removed,  a  carefully  conducted  bacteriological  examination, 
with  systematic  endeavor  to  cultivate  in  every  known  culture 
medium  whatever  living  parasites  may  be  obtained.  As  soon 
as  means  and  space  are  afforded  it  is  intended  to  conduct  also 
most  minute  inA'estigations  into  physiological  chemistry,  in- 
cluding chemical  and  spectroscopic  examinations  of  all  the 
fluids,  chemical  analysis  of  secretions,  etc.  ...  So  soon,  also,  as 
the  State  places  sufficient  means  at  command  it  is  intended  to 
institute  a  series  of  examinations  of  whatever  specimens  may 
be  sent  us,  just  as  at  present  in  various  city  laboratories  sus- 
pected sputum  or  exudate  are  examined  for  the  determination 
of  diphtheria,  tuberculosis,  etc." 

This  laboratory  at  Buffalo  was  the  first  to  be  devoted  ex- 
clusively to  the  investigation  of  cancer.  It  was  definitely  taken 
over  by  the  State  in  1901,  and  has  since  been  known  as  the 
Cancer  Laboratory  of  the  l^ew  York  State  Board  of  Health. 
Subsequently  it  has  been  housed  at  the  Gratwick  Research  Lab- 
oratory, of  the  University  of  Buffalo. 

On  November  1,  1913,  the  Research  Hospital  of  the  State 
Institute  for  the  Study  of  Malignant  Disease,  was  formally 
opened.  Ewing,^  who  made  the  address  on  this  occasion,  thus 
pointed  out  its  significance — ''When  a  State  legislature  com- 
mits itself  to  clinical  cancer  research  and  devotes  public  funds 
to  this  purpose,  it  establishes  important  precedents." 

CANCER    COMMISSION    OF    THE    HARVARD    UNIVERSITY 

The  surgical  department  of  the  Harvard  Medical  School 
organized  the  above  body  of  investigators  in  1899.  The  Com- 
mission owes  its  existence  to  the  generosity  of  the  late  Caroline 
Brewer  Croft,  and  the  work  has  been  continued  in  the  Medical 
School,  especially  in  the  department  of  surgery,  by  means  of 
this  gift  and  other  sums  contributed  more  recently  to  the  cause 
of  cancer  research.  For  twelve  years  the  work  was  largely 
restricted  to  the  laboratory  study  of  cancer,  the  investigations 
being  conducted  in  the  laboratories  of  the  Harvard  Medical 
School  and  at  the  Massachusetts  General  Hospital.     The  lab- 

lEwing,  James. — "The  Cancer  Kesearch  Hospital,"  N.  Y.  Med.  Jour., 
December  27,  1913,  p.  1241. 


HISTORY  7 

oratories  of  the  Medical  School  and  of  the  different  science 
departments  of  Harvard  University  are  still  utilized  for  the 
laboratory  studies.  Since  April,  1912,  however,  the  clinical 
researches  have  been  made  in  the  Collis  P.  Huntington  Memor- 
ial Hospital,  endowed  by  Mrs.  Huntington. 

The  aim  of  the  hospital  '4s  the  study  of  special  problems 
with  the  view  of  adding  to  the  knowledge  of  the  natural  history 
and  the  rational  treatment  of  tumors,  and  also  to  be  of  public 
service  in  affording  means  for  early  diagnosis  and  in  carrying 
out  treatment  or  giving  advice  regarding  therapeutic  meas- 
ures." 

''Another  aspect  of  the  work  of  the  Huntington  Hospital,  of 
less  value  to  the  world  at  large,  but  of  incalculable  benefit  to 
the  individual,  is  the  opportunity  offered  of  supplying  modern 
hospital  care  to  the  inoperable  or  recurrent  cases  of  cancer  for 
which  other  hospitals  in  the  community  have  no  place." 

The  hospital  provides  accommodations  for  twenty-five  in- 
patients.    Out-patients  are  received  at  stated  hours. 

An  important  part  of  the  work  of  the  institution  involves 
the  keeping  of  complete  and  accurate  clinical  and  pathological 
records  of  all  cases. 

Dr.  E.  E.  Tyzzer,  Assistant  Professor  of  Pathology,  is  Di- 
rector of  the  Cancer  Commission,  and  Dr.  Thomas  Ordway, 
Instructor  in  Medicine,  is  Physician  in  Charge  of  the  Hunting- 
ton Hospital. 

CANCER    RESEARCH    IN    GERMANY 

In  Germany,  as  in  the  United  States,  the  movement  was 
inaugurated  on  the  basis  of  cancer  being  infective.  Professor 
von  Leyden  and  Professor  George  Meyer,  the  interest  and  influ- 
ence of  Professor  Kirchner  having  been  obtained,  called  a 
meeting,  which  was  held  at  the  Kultusministerium,  Berlin,  on 
February  18,  1900.  It  was  attended  by  ten  representative 
persons  who  constituted  themselves  into  "Die  Comite  flir 
Krebsforschung"  (The  Committee  for  Cancer  Research). 
Preparations  already  made  enabled  the  Committee,  with  Gov- 
ernment assistance,  to  immediately  advance,  on  October  15, 
1900,  to  the  taking  of  a  census  of  all  cases  of  cancer  in  Ger- 
many. This  proceeding,  and  many  other  steps  taken  or  advo- 
cated by  this  Committee,  w^ere  determined,  as  in  the  case  of 
Roswell  Park  in  America,  by  the  belief  that  cancer  is  an  infec- 
tive disease  closely  analogous  to  tuberculosis.  At  the  inaugural 
meeting  mentioned,  Professor  Kirchner  was  able  to  announce 
with  the  authority  of  the  Kultus  Minister — the  famous  Althoff 
— that  the  Government  would  assist,  because  "Since  a  parasitic 


S  THE    CANCER    PROBLEM 

etiology  is  supposed,  which  view  the  speaker  also  inclined  to, 
there  is  the  possibility  of  seriously  considering  the  prevention 
of  this  disease.  Because  it  is  the  duty  of  the  State  to  take  its 
share  in  the  suppression  of  avoidable  diseases,  there  can  be  no 
doubt  that  the  State  officials  will  participate.  The  Kultus  Min- 
ister, and  the  Directors  of  the  Departments  for  Education  and 
Medicine,  express  their  lively  interest  in  the  matter.  The 
Director  Althotf  is  prevented  from  being  present  by  official 
business.  Geheimrat  Forster,  who  is  unfortunately  prevented 
from  being  present,  is  willingly  ready  to  collaborate." 

Tlius  was  inaugurated  a  scheme  which  has  given  rise  to  wide 
discussion  and  controversy,  not  only  in  Germany  but  prac- 
tically throughout  the  world,  because  the  enthusiasm  of  this 
band  of  public-spirited  men  speedily  attracted  followers  in 
Europe  and  America.  The  Committee  issued  the  Zeitschrift 
fiir  Krehsforscliung ,  and  in  other  ways  stimuli  were  ever 
emanating  from  Berlin  to  encourage  those  in  other  countries 
to  imitate  their  example  by  founding  committees  and  taking 
cancer  censuses.  The  addition,  in  1900-1,  of  a  department  for 
cancer  to  the  Royal  Institute  of  Experimental  Therapeutics, 
Frankfort-on-Main,  arose  out  of  the  influence  which  this  Com- 
mittee exerted  on  the  Government  authorities,  as  did  also 
the  provision,  under  von  Leyden,  for  special  wards  and  labo- 
ratories for  cancer  in  the  famous  Berlin  hospital.  The  Charite. 

Throughout  Germany  there  have  been  formed  local  com- 
mittees in  the  large  tovms  and  in  almost  all  of  the  federated 
states.  There  has  been  an  organized  effort  to  educate  the  pub- 
lic in  the  early  s}anptoms  of  cancer,  and  a  list  has  been  issued 
recently  of  institutions  which  will  undertake  the  microscopical 
examination  of  growths,  as  well  as  of  dispensaries  where  advice 
may  be  sought. 

INTERNATIONAL    ASSOCIATION    FOR    CANCER    RESEARCH 

Out  of  the  efforts  of  those  who  had  participated  in  different 
countries,  in  founding  societies  and  in  their  affiliation  with  the 
Berlin  Committee,  there  grew  up  the  International  Association 
for  Cancer  Research,  which  has  had  a  checkered  career.  It 
was  inaugTirated  with  enthusiasm  at  Heidelberg  at  the  opening 
ceremony  of  Czerny's  Institute,  in  1906,  when  a  first  Inter- 
national Conference  was  held.  A  second  Conference  was  held 
in  Paris,  in  1910.  This  assumed  the  dimensions  of  an  Inter- 
national Congress,  attended  by  government  plenipotentiaries 
from  twenty-three  countries;  but  internal  dissensions,  arising 
out  of  questions  of  organization,  policy,  office  bearers,  and  the 


HISTORY  9 

seat  of  the  permanent  secretarial  bureau,  were  apparent.  Eng- 
land and  Norway  persisted  in  refusing  to  join  the  Interna- 
tional Association,  and  France  subsequently  withdrew  from 
membership.  A  third  Conference,  held  in  Brussels,  in  1913, 
attained  to  nothing  like  the  same  proportions,  and  attracted 
little  attention.  A  fourth  Conference  is  foreshadowed  in  Den- 
mark, in  1916. 

From  the  outset  the  proceedings  of  the  Cancer  Committee 
met  with  criticism  on  the  part  of  the  many  famous  pathologists 
in  Germany  who  did  not  care  to  associate  themselves  with  a 
policy  and  proceedings  based  upon  the  foregone  conclusion  that 
cancer  is  a  parasitic  disease.  All  of  them,  with  the  exception 
of  von  Hansemann,  held  aloof,  and  there  were  at  least  two  or 
three  notable  disclaimers  of  any  share  in  the  responsibility  for 
the  views  expressed  on  behalf  of  the  Committee.  The  taking 
of  a  cancer  census  (in  1902-3)  also  speedily  met  with  Bash- 
ford's  criticism.  He  maintained  that  it  would  fulfil  no  useful 
purpose  in  England,  and  that  it  should  not  be  imitated  in  that 
country,  claiming  that  it  was  unsound  statistically  and  a  need- 
less expenditure  of  money. 

The  domestic  difficulties  of  the  German  Committee  natu- 
rally extended  to  the  international  relationships  it  attempted  to 
establish.  The  policy  originally  laid  down  was  persisted  in, 
unfortunately,  with  great  obstinacy.  Had  the  views  of  the 
Committee  and  its  proceedings  been  made  more  consonant  with 
what  is  actually  established,  it  is  possible  that  minor  difficulties 
of  organization  would  have  been  overcome  through  the  associa- 
tion of  other  and  more  numerous  representative  men,  and  that 
a  truly  representative  international  association  would  have  been 
formed.  Bashford,^  who  throughout  had  been  the  chief 
spokesman  of  those  opposed  to  the  policy  originally  pursued  by 
the  German  Cancer  Committee,  and  to  the  taking  of  cancer 
censuses,  plainly  restated  this  position  at  Paris  in  1910. 

The  British  Medical  Journal,"  commenting  editorially  upon 
the  proceedings  of  the  second  conference,  said : 

"In  Great  Britain  they  had  not  a  society  or  committee  mod- 
eled upon  the  lines  of  those  affiliated  with  the  International 
Association,  and  Dr.  Bashford  explained  that  as  he  was  there 
as  the  representative  of  the  British  Government  at  the  invita- 
tion of  the  French  Foreign  Office,  therefore  he  was  not  present 
as  an  actual  member  of  the  International  Association,  but 
^  Bashford,  E.  F. — Verhandlung  des  Komitees  fur  Krehsforschung,  Heft 
III,  1903-4,  reprinted  from  Deut.  med.  Woch.,  1904;  First  Annual  Eeport 
Imperial  Cancer  Research  Fund,  1903 ;  Second  Scientific  Eeport  Imperial 
Cancer  Research  Fund,  Part  I,  1905;  etc. 
'October  22,   1910,   p.   1266. 


10  THE    CANCER    PROBLEM 

rather  as  a  guest  of  the  French  Association.  As  was  well 
known  to  his  fellow  delegates,  Great  Britain  had  hitherto  held 
aloof  from  membership  of  the  International  Association.  That 
abstention  implied  no  unwilling-ness  to  collaborate,  practically, 
with  other  nations;  on  the  contrary,  it  was  common  knowledge 
how  materially  British  investigators  had  assisted  their  foreign 
colleagues.  The  abstention  of  Great  Britain  from  affiliation 
with  the  International  Association  had  no  political  significance 
whatsoever,  no  matter  what  might  have  been  inferred  to  the 
contrary;  it  was  based  upon  purely  scientific  grounds  only. 
The  presence  of  an  official  representative  of  the  British  Gov- 
ernment was  due  to  the  importance  attached  in  all  quarters, 
from  the  highest  to  the  lowest,  to  the  study  of  cancer  in  Eng- 
land, and  was,  on  the  one  hand,  an  official  recognition  of  the 
success  with  which  it  had  been  organized  in  Great  Britain  by 
a  number  of  institutions  in  addition  to  the  Imperial  Cancer 
Besearch  Fund,  of  which  he  (Dr.  Bashford)  had  the  privilege 
to  be  the  Director.  On  the  other  hand,  the  presence  of  an  offi- 
cial representative  of  the  British  Government  was  evidence  of 
the  interest  of  all  in  England  in  the  proceedings  of  the  Inter- 
national Association,  and,  in  particular,  in  the  proceedings  of 
this  Second  International  Conference.  Although  not  at  pres- 
ent a  member  of  the  International  Association — a  fact  which 
he  felt  bound  to  emphasize — Dr.  Bashford  stated  that  he  es- 
teemed it  a  high  honour,  a  privilege,  and  a  pleasure  to  be  the 
guest  of  the  French  Association;  in  previous  years  he  had 
entertained  the  same  sentiments  when  he  had  been  the  guest  of 
the  German  Association  in  Berlin  and  in  Heidelberg. 

"Although  in  England  they  inclined  to  the  belief  that  the 
present  was  rather  a  time  for  work — much  work — in  the  hope 
of  advancing  knowledge  of  the  disease  of  which  they  knew 
practically  nothing,  and  could  do  little  or  nothing  to  prevent, 
rather  than  a  time  for  the  holding  of  congresses,  which  they 
thought  were  premature,  since  they  had  nothing  revolutionary 
to  discuss  or  to  agree  upon,  still  such  a  conference  as  the  present 
might  fulfil — indeed,  his  presence  proved  that  he  hoped  it 
would  fulfil — a  useful  purpose." 

An  interesting  exchange  of  views  occurred  at  the  closing 
ceremony.  The  President,  von  Czerny,  made  a  direct  appeal 
to  Dr.  Bashford  to  use  his  influence  to  obtain  the  adhesion  of 
Great  Britain  to  the  International  Association. 

In  replying  to  this  appeal,  Dr.  Bashford  ^  "assured  his 
hearers  that  his  presence  attested  to  the  fact  that  in  England 
they  had  no  objection,  in  principle,  to  such  conferences,  pro- 
'  Editorial,  Brit.  Med.  Jour.,  loc.  cit.,  p.  1268. 


HISTORY  11 

vided  they  fulfilled  a  useful  purpose,  nor  had  they  the  least 
objection  to  an  international  association  for  the  study  of  can- 
cer, provided  its  international  character  was  assured,  and  it 
was  the  outward  expression  of  a  workable,  practicable  scheme 
of  collaboration.  Speaking  as  the  Director  of  the  Imperial 
Cancer  Research  Fund,  Dr.  Bashford  said  that  he  need  hardly 
remind  them  how  substantially  that  institution  had  endeavoured 
to  support  foreign  workers,  great  and  small,  and  in  many  coun- 
tries, by  distribution  of  material  and  other  means,  as  well  as 
by  receiving  them  as  guests  in  its  laboratories.  This  had 
seemed  to  them  international  collaboration  of  a  practical  and 
useful  kind.  Addressing  the  more  prominent  German  dele- 
gates by  name,  and  speaking  in  German,  Dr.  Bashford  assured 
them  how  highly  he  valued  the  foreign  membership  of  the  Ger- 
man Committee  and  his  intercourse  with  its  members.  Having 
expressed  the  honour  and  the  pleasure  it  had  been  to  him  to  be 
again  associated  in  Paris  with  his  German  colleagues,  he  con- 
gratulated von  Czerny  on  the  fruitful  result  of  ideas  first 
mooted  at  the  opening  of  his  Cancer  Institute  in  Heidelberg 
in  1906,  from  which  had  sprung  this  second,  larger,  and  suc- 
cessful international  conference." 

When,  if  ever,  the  inner  history  of  the  various  moves  in  this 
controversy  comes  to  be  made  public,  it  will  be  found  how 
steadfastly  one  man  withstood  the  influences  brought  to  bear, 
in  favor  of  what  he  held — and  as  the  course  of  events  has 
shown,  rightly  held — was  a  mere  scheme  on  paper.  Even  ques- 
tions addressed  to  the  Prime  Minister  in  the  British  House  of 
Commons,  and  even  a  petition  presented  to  King  Edward  VII. 
during  his  visit  to  Berlin,  did  not  alter  the  conclusion  come  to, 
that  the  cause  of  the  investigation  of  cancer  would  be  better 
advanced  by  other  methods  than  those  advocated  by  the  Berlin 
Committee.  Unfortunately,  the  hopes  which  Czerny  held  out, 
that  the  objections  would  be  removed,  have  not  been  realized. 
England  and  Norway  still  stand  aloof,  France  has  withdrawn, 
and  the  adhesion  of  many  other  countries,  like  Greece,  Persia, 
Argentina,  Peru,  Bolivia,  Turkey,  and  China,  has  little  scien- 
tific or  practical  value. 

CANCER    RESEARCH    IN    ENGLAND 

In  England,  during  a  series  of  years,  many  eminent  sur- 
geons had  repeatedly  drawn  attention  to  what  they  held  was  an 
alarming  increase  of  cancer,  calling  for  urgent  investigation; 
but  the  new  era  in  endeavors  to  probe  the  mysteries  of  cancer 
may  be  dated  from  April,  1899,  when  Malcolm  Morris — now 


12  THE    CANCER    PROBLEM 

Sir  Malcobn  Morris — issued  a  special  number  of  The  Prac- 
titioner,^ of  which  journal  he  was  then  editor. 

"The  Editor  wishes  it  to  be  clearly  understood,"  he  said  in 
the  editorial  preface  to  this  number,  "that  he  has  no  idea  of 
starting  a  movement  for  the  suppression  of  cancer  such  as  has 
been  initiated  with  good  prospect  of  success  in  regard  to  tuber- 
culosis. In  the  present  state  of  our  knowledge  the  efforts  of 
an  association  for  the  prevention  of  cancer  would  be  as  purpose- 
less and  as  futile  as  the  wanderings  of  Don  Quixote  in  search 
of  chivalrous  adventure.  And  we  should  be  as  poorly  equipped 
for  such  a  campaign  as  the  knight  of  La  Mancha  with  his 
pasteboard  helmet  and  his  bareboned  charger.  The  movement 
for  the  prevention  of  tuberculosis  finds  its  justification  in  the 
reasonable  hope  there  is  of  success,  and  this  hope  lies  in  the 
fact  that  the  cause  of  the  disease  is  positively  known,  and  the 
means  of  counteracting  its  operations  are  in  our  hands.  The 
case  is  altogether  different  as  regards  cancer.  Its  cause  is  still 
hidden,  or  at  least  too  uncertain  to  be  treated,  in  the  practical 
sphere,  otherwise  than  as  an  unknown  quantity.  Some  of  the 
best  investigators  have  for  years  past  been  striving  to  wrest 
this  secret  from  Nature.  But  life  is  short  and  the  labour  needed 
for  the  solution  of  the  problem  is  long  and  arduous.  If  a  col- 
lective investigation  of  the  aetiology  of  cancer  could  be  organ- 
ized on  a  sufficiently  large  scale,  the  prospect  of  ultimate  suc- 
cess would  be  greatly  increased.  By  'collective  investigation' 
is  not  meant  the  sending  out  broadcast  of  schedules  of  ques- 
tions, the  answers  to  which  are  dealt  with  by  a  committee 
which  endeavours  to  extract  a  kind  of  essence  from  the  mass. 
Information  collected  in  this  manner  may  be  of  some  value 
from  the  purely  statistical  point  of  view,  but  it  is  worthless 
for  the  elucidation  of  a  pathological  problem.  What  appears 
to  be  required  is  the  formation  of  a  band  of  scientific  experts 
scattered  through  a  number  of  laboratories  in  different  parts  of 
the  world,  all  in  touch  with  each  other.  The  work  should  be 
organized  as  astronomical  research  is,  each  group  being  at  once 
informed  of  any  observation  made  elsewhere,  so  that  it  may  be 
tested,  and  of  any  new  line  of  research  being  opened,  so  that 
it  may  be  followed  up.  There  is  too  much  individualism  in 
scientific  work,  and  the  result  is  not  only  waste  of  power,  but 
actual  loss  of  knowledge,  which  is  allowed  to  die  with  its  dis- 
coverer because  he  could  not  get  a  hearing  for  it,  or  because  it 
failed  to  find  favour  in  the  eyes  of  some  superior  person.  With 
a  proper  organization  of  research  on  definite  lines  by  a  number 
of  investigators  working  together  to  a  definite  end,  there  would 
'  The  Practitioner,  April,  1899,  Vol.  LXII,  p.  362. 


HISTORY  18 

be  little  or  no  leakage,  and  success  would  be  merely  a  matter 
of  time." 

Conspicuous  examples  of  cancer  research  organizations  in 
England  are  found  in  the  Cancer  Department  of  the  Middle- 
sex Hospital,  which  combines  the  clinical  with  the  laboratory 
investigation,  and  the  Imperial  Cancer  Research  Fund,  which 
confines  its  work  to  the  laboratory  and  statistical  study  of  the 
disease. 

Because  these  institutions  represent  distinct  types  they  are 
discussed  somewhat  more  at  length  than  are  other  research 
organizations. 

CANCER    RESEARCH    LABORATORIES,    MIDDLESEX    HOSPITAL 

Independently  of  the  movement  thus  initiated  by  Sir  Mal- 
colm Morris,  steps  were  being  taken  to  have  the  Cancer  Wards 
of  the  Middlesex  Hospital  associated  with  a  special  investiga- 
tion department. 

From  1792  up  to  the  present  day,  the  Cancer  Department  of 
the  Middlesex  Hospital,  London,  has  remained  a  distinctive 
feature  of  the  establishment,  affording  not  only  a  refuge  for  a 
vast  number  of  those  suffering  from  cancer,  but  also  oppor- 
tunity for  investigation  and  for  the  testing  of  alleged  remedies. 
The  objects  of  the  donor,  Mr.  Whitbread,  were  therefore  two- 
fold— the  relief  of  suffering  and  the  investigation  of  the  dis- 
ease. Mr.  Howard,  who  acted  as  intermediary  for  the  bene- 
factor, expressed  himself  as  regards  the  second  object  as 
follows.^ 

"With  regard  to  the  second  object,  namely,  the  investigation 
of  the  disease,  Lord  Bacon  has  observed  that  medical  men 
should  make  themselves  proficients  in  physic  by  studying  one 
disease  at  a  time.  It  is  an  opinion  worthy  of  so  great  a  man; 
it  was  particularly  adopted  by  the  late  Mr.  Pott,  and  by  him 
recommended  to  all  students  in  surgery. 

"By  confining  one  or  more  wards  to  cancer  only,  the  attention 
of  pupils  and  others  will  be  directed  very  strictly  to  the  study 
of  this  disease.  They  will  see  facts  as  they  arise  in  the  aggre- 
gate from  a  large  number  of  patients ;  new  lights  will  appear, 
and  new  discoveries  will  probably  be  made. 

"  'I  have  often  thought,'  says  Dr.  Sydenham,  'that  if  I  knew 
accurately  the  natural  history  of  any  disease,  I  should  never  be 
at  a  loss  for  a  proper  method  of  treating  it' ;  and  the  wonderful 

'Coupland,  Sidney. — "The  Cancer  Charity  of  the  Middlesex  Hospital, 
1792-1902."  Eeports  from  the  Cancer  Eesearch  Laboratories  of  the  Mid- 
dlesex Hospital,  Vol.  I,  London,  1902,  p.  1. 


14  THE    CANCER    PROBLEM 

improvements  he  made  in  science  bj  his  great  attention  to  the 
natural  history  of  diseases,  and  the  effects  of  medicine  upon 
them,  have  been  justly  admired  by  practitioners  of  every  coun- 
try. {Vide  the  Preface  to  Dr.  Sydenham's  "Observations  on 
the  History  and  Cure  of  Acute  Diseases.") 

"The. natural  history  of  caucers,  although  a  common  disease 
in  the  enlarged  comprehensive  sense  in  which  this  great  man 
understood  the  natural  history  of  diseases,  is  but  little  known, 
I  would  therefore,  in  order  to  improve  a  subject  on  which  a 
successful  practice  greatly  depends,  propose  that  a  faithful 
account  of  the  history  and  circumstances  of  every  case  be  kept : 
its  antecedents  and  consequences  should  be  marked,  the  effects 
of  medicine  and  of  operations,  when  necessary,  noted,  together 
with  all  the  collateral  helps  to  be  gained  by  an  inquiry  into 
constitutional  habits  and  diseases  not  strictly  cancerous,  but 
probably  connected  with  it.  This  examination  may  be  made  by 
a  medical  gentleman  of  the  hospital  with  the  patient  before 
him,  his  notes  to  be  corrected  by  himself,  and  kept  as  a  record 
of  the  history  and  circumstances  of  each  case,  to  be  recurred  to, 
as  an  authority,  by  any  intelligent  or  scientific  person.  A  copy 
of  these  notes  may  be  kept,  fairly  written,  for  general  inspec- 
tion ;  and  if  anything  extraordinary  or  worthy  of  more  particu- 
lar notice  arise  from  these  sources,  let  the  circumstances  be  pub- 
lished to  the  world  at  large. 

"By  an  institution  comprehending  the  two  objects  now 
pointed  out,  I  have  a  hope  not  only  that  the  diseased,  but  that 
practitioners  in  general  may  be  benefited,  that  much  useful 
knowledge  may  be  disseminated,  and  that  we  may,  in  no  gi'eat 
length  of  time,  be  furnished  with  documents  on  the  disease  and 
cure  much  more  authentic  than  any  we  are  at  this  time  in  pos- 
session of.  It  is  a  very  important  subject  of  inquiry,  equally 
interesting  to  the  rich  and  independent  part  of  mankind  as  to 
the  poor ;  and  if  such  an  institution  be  fairly  set  on  foot,  it  can- 
not fail  of  producing  beneficial  consequences  to  all  descriptions 
of  persons  labouring  under  this  dreadful  malady." 

Since  the  foundation  of  the  Cancer  Ward,  in  1792,  various 
extensions  and  improvements  have  been  undertaken,  and  in 
1896  a  more  ambitious  nature  was  given  to  the  establishment 
when  plans  for  a  new  cancer  wing  were  approved.  The  new 
cancer  wing  was  approaching  completion  in  February,  1899, 
and,  not  unmindful  of  the  wishes  of  the  original  founder,  at 
a  meeting  of  the  Weekly  Board,  on  February  7,  1899,  "the 
Chairman  having  made  a  statement,  as  a  preliminar}^,  in  view 
of  the  opening  of  the  New  Wing  for  Female  Cancer  Patients, 
and  more  particularly  in  regard  to  its  medical  supervision  for 


HISTORY  15 

carrying  out  the  wishes  of  the  original  founders  of  the  Cancer 
Wards,  it  was,  after  some  discussion,  moved  by  Sir  Arthur 
Watson,  seconded  by  the  Hon.  Spencer  Lyttleton,  and  resolved 
unanimously : 

"That  the  Weekly  Board  of  Governors  are  of  opinion  that, 
in  the  arrangements  to  be  made  for  the  medical  supervision  of 
the  new  Female  Cancer  Wards,  endeavours  should  be  made  to 
give  effect  to  the  wishes  of  the  original  founders,  which  are 
expressed  in  the  conditions  submitted  by  the  late  Samuel  Whit- 
bread,  Esq.,  in  1791,  in  the  following  terms,  viz.:  'The  relief 
of  persons  affected  with  Cancer,  and  the  investigation  of  a  com- 
plaint which,  though  extremely  common,  is,  both  with  regard 
to  its  natural  history  and  cure,  but  imperfectly  known' ;  and 
likewise  laid  down  in  the  will  of  the  late  Mrs.  Alithea  Maria 
Stafford,  as  follows,  viz. :  'Curing  persons  affected  with  Can- 
cer, and  of  investigating  and  promoting  our  general  knowledge 
of  treating  that  dreadful  disorder.'  And  the  Board  would  be 
glad  if  the  Medical  Committee  would  consider  how  this  could 
best  be  done.  The  enhanced  facilities  for  pathological  and  bac- 
teriological study  in  the  Hospital  is,  they  consider,  an  addi- 
tional reason  why  some  practical  steps  should  be  taken  in  this 
direction. 

"In  establishing  the  Cancer  Research  Laboratories  the  Gov- 
ernors of  The  Middlesex  Hospital  have  not  only  been  faithful 
to  the  trust  confided  to  them,  but  they  have  set  an  example  to 
others  similarly  engaged  in  the  warfare  against  disease.  They 
have  perceived  that  the  only  sure  foundation  upon  which  suc- 
cessful treatment  can  be  based  is  that  of  knowledge  of  the  na- 
ture and  causes  of  diseases.  In  such  investigations  as  can 
alone  be  carried  on  into  the  difficult  and  complex  problems  of 
cancerous  affections,  it  may  be  long  before  any  decided  practi- 
cal result  can  be  attained.  But  the  labour  will  not  be  thrown 
away.  Every  additional  fact,  however  small,  will  contribute  to 
the  better  understanding  of  the  conditions  under  which  such 
diseases  arise  and  the  manner  in  which  they  spread.  That  in 
due  time  such  knowledge  will  be  the  means  of  directing  us 
where  to  look  for  the  means  of  checking  and  preventing  cancer 
there  can  be  little  doubt.  Such  a  consummation  will,  however, 
only  be  attained  by  the  exercise  of  unwearied  patience  and 
assiduity  by  those  engaged  in  the  task."  ^ 

At  a  later  date  Dr.  Lazarus-Barlow  became  Director  of  The 
Middlesex  Hospital  Cancer  Investigation  Department,  which, 
in  1909,  underwent  an  important  extension  and  reorganization 
in  consequence  of  the  Barnato  Bequest.      The  investigations 

'  Coupland,  loc.  cit.,  p.  34. 


16  THE    CANCER    PROBLEM 

imder  Dr.  Lazarus-Barlow's  leadership  have  become  closely 
identified  with  the  stiid_y  of  radium  as  a  possible  constituent 
of  tumors  as  well  as  a  therapeutic  agent. 

IMPERIAL    CANCER    RESEARCH    FUND 

In  the  First  Report  from  the  Cancer  Research  Laboratories 
of  The  Middlesex  Hospital,  Dr.  Sidney  Coupland  gives  an  in- 
teresting and  valuable  summary  of  what  had  been  done  up  to 
1902,  with  a  succinct  statement  of  the  object  of  the  work.  This 
summary  ends  as  follows:^  "Finally,  the  present  year 
(1902)  has  seen  the  formation  in  this  country  [England], 
under  the  auspices  of  the  Royal  College  of  Physicians  of  Lon- 
<lon  and  the  Royal  College  of  Surgeons  of  England,  of  what 
may  be  regarded  as  a  National  Committee  for  the  promotion 
of  Cancer  Research." 

This  organization,  originally  known  as  the  Cancer  Research 
Fund,  in  recognition  of  investigations  which  had  developed 
throughout  the  British  Dominions,  had  the  title  of  Imperial 
Cancer  Research  Fund  bestowed  upon  it  in  July,  1904,  by 
King  Edward. 

The  development  of  the  work,  whose  inception  dates  from  a 
conversation  between  a  private  gentleman  and  a  member  of 
the  Council  of  the  Royal  College  of  Surgeons  of  England,  in 
1901,  was  placed  in  control  of  the  Royal  College  of  Physicians 
and  Surgeons. 

A  General  Committee  was  appointed  by  these  bodies  to  for- 
mulate a  scheme  of  research,  and  as  the  result  of  their  delib- 
erations, extending  over  many  meetings,  a  plan  was  approved 
on  July  4,  1902. 

As  soon  as  the  sum  of  £30,000  was  in  hand  the  two  Royal 
Colleges  consented  to  inaugurate  the  investigations,  with 
the  full  understanding  that  with  so  small  a  sum  it  would 
be  necessary  to  spend  the  capital  and  to  limit  the  scope  of  the 
work. 

The  organization  and  objects  of  the  scheme  have  been  offi- 
cially described,^  in  part,  as  follows: 

In  order  to  promote  investigations  into  all  matters  con- 
nected with  or  bearing  on  the  causes,  prevention,  and  treatment 
of  cancer  and  malignant  disease,  steps  shall  be  taken : 

"1.  To  provide,  extend,  equip,  and  maintain  laboratories  to 
be  devoted  to  cancer  research. 

•  Loc.  cit.,  p.  38. 

*  Lancet,  July  12,  1902,  p.  101. 


HISTORY  17 

"2.  To  encourage  researches  on  the  subject  of  cancer  within 
the  United  Kingdom  or  in  the  British  Dominions  beyond  the 
seas, 

"3.  To  assist  in  the  development  of  cancer  research,  in  vari- 
ous hospitals  and  institutions  approved  by  the  executive  com- 
mittee. 

"4.  And  generally  to  provide  means  for  systematic  investi- 
gation into  the  causes,  prevention,  and  treatment  of  cancer. 

"Should  the  objects  of  the  Fund  be  attained  by  the  discovery 
of  the  cause  and  nature  of  cancer,  and  of  an  effective  method 
of  treatment,  the  Royal  Colleges,  with  the  consent  of  the  Trus- 
tees, shall  be  empowered  to  utilize  the  Fund,  (a)  for  equipping 
with  the  necessities  for  such  treatment  such  hospitals  as  they 
may  select,  or  (b)  for  forwarding  research  into  other'  dis- 
eases." 

It  was  decided  that  the  affairs  of  the  Fund  be  administered 
by  the  president,  vice-presidents,  five  trustees,  a  general  com- 
mittee, an  executive  committee,  a  working  and  consultative 
staff. 

The  investigations  were  set  going  in  October,  1902,  on  the 
basis  of  a  draft  scheme  for  inquiring  into  the  nature,  cause,  • 
prevention,  and  treatment  of  cancer,  drawn  up  by  Dr.  E.  F. 
Bashford  previous  to  his  appointment  as  General  Superinten- 
dent of  Research.  A  few  months  later  Dr.  Bashford  was  also 
elected  director  of  the  laboratory.  This  scheme  is  reprinted 
from  the  Third  Scientific  Report  of  the  Imperial  Cancer  Re- 
search Fund,  1908,  p.  441. 

"1.     General,  Nature  of  the  Enquiry  and  General  Or- 
ganisation. 

"Scope. 

"The  term  'Cancer'  must  be  taken  to  include  all  malignant 
new  growths,  and  this  conception  must  be  extended  to  similar 
diseases  in  animals,  both  for  studying  the  subject  in  them,  and 
in  relation  to  the  possibility  of  transmission  to  man. 

"Character  Constituting  Malignancy  and  Spread. 

"The  investigation  must  further  include  the  conditions 
favourable  to  spread  in  the  body  and  the  other  features  of 
malignancy,  since  these  constitute  the  serious  aspect  of  cancer 
as  distinct  from  innocent  growths.  Any  change  which  would 
prevent  the  acquisition  of  malignancy,  or  which  would  hinder 
such  spread,  would  be  of  very  great  value. 


18  THE    CANCER    PROBLEM 

^'Statistics  as  to  Incidence.     General  Causes. 

"The  enquiry  should  include  the  compilation  of  accurate 
statistics  bearing  on  all  the  conceivable  conditions  possibly 
associated  with  the  incidence  of  the  disease. 

"The  Possibility  of  Different  Causation  in  Different  Groups; 
Separation  of  Special  Groups,  some  possibly  Parasitic. 

"The  study  of  all  new  growths  in  order  to  classify  them,  and 
to  distinguish  the  various  forms  which  at  present  may  be 
grouped  together  as  malignant  growths  is  important.  It  might 
thus  be  possible  to  eliminate  some  types  which  may  be  found 
to  be  of  definite,  and  possibly  of  very  diverse  parasitic  origin. 
This  will  constitute  an  important  feature  of  the  work  to  be 
done. 

"Experimental  Production  of  'Cancer.' 

"It  will  be  necessary  to  attempt  to  produce  new  growths  in 
various  ways,  or  to  attempt  so  to  modify  non-malignant  growths 
that  they  become  malignant. 

"Bio-chemical  and  Physiological,  possibly  including  Therapeu- 
tic Substances. 

"Investigations  along  modern  bio-chemical  lines,  with  con- 
sideration of  the  conceivable  production  of  cytolytic,  agglutina- 
tive, antagonistic,  perhaps  therapeutic  sera,  and  the  possible 
occurrence  and  antagonistic  nature  of  internal  secretions,  etc., 
will  demand  very  serious  attention. 

"The  organization  will  consist  of: 

"(1)  A  central  bureau  and  laboratory  for  general  direc- 
tion of  the  undertaking,  for  study,  research,  control  of  work 
being  done  and  of  the  results  obtained  elsewhere,  and  for  the 
summarising  of  results  and  the  interpretation  of  statistical  in- 
vestigations by  those  working  there. 

"(2)  Associated  workers  carrying  on  special  parts  of  the 
investigation  in  their  own  laboratories  or  hospitals,  etc.  There 
would  thus  be  an  attempt  to  utilise  so  far  as  possible  existing 
laboratories,  and  also  skilled  workers,  who  occupy  other  im- 
portant positions. 

"(3)  Other  persons  from  whom  statistics  might  be  col- 
lected, etc. 

"The  ultimate  greater  development  of  the  experimental  side 
of  the  enquiry  being  borne  in  mind,  the  control  work  might  be 


HISTORY  19 

begun  by  classifying  all  that  is  grouped  under  the  term  malig- 
nant disease,  and  by  collecting  statistics. 

"At  the  outset  two  or  three  rooms  giving  accommodations 
for  the  director,  one  or  two  good  secretarial  assistants,  and  two 
or  three  assistants  skilled  in  microscopical  work  would  be  re- 
quired. 

"At  a  subsequent  date  the  investigation  will  in  all  probability 
require  much  more  extensive  laboratory  accommodations,  and 
it  will  be  necessary  to  obtain  some  place  where  animals  can  be 
bred  and  kept,  and  probably  a  farm  will  be  required. 

"Of  the  skilled  assistants,  one  should  if  possible  be  a  trained 
veterinary  surgeon  who,  apart  from  his  special  duties  in  con- 
nection with  the  important  veterinary  aspects  of  the  research, 
would  at  a  later  date  be  invaluable  in  regard  to  supervision  of 
animals  destined  for  research  purposes. 

"In  an  enquiry  which  may  ultimately  require  the  keeping 
of  many  animals,  both  of  the  larger  forms,  e.  g.,  horses,  an- 
thropoid apes,  etc.,  proper  attention  to  the  hygiene  of  the 
animals  would  be  essential;  apart  from  the  experimental  im- 
portance of  being  able  to  exclude  previous  infection,  ultimately 
a  proper  farm  with  efficient  means  for  isolation  and  perhaps 
for  the  breeding  of  animals  would  be  necessary. 

"A  second  assistant  should  be  especially  detailed  to  assist 
in  the  bio-chemical  researches,  and  should  have  had  a  proper 
chemical  training,  if  possible;  also  a  training  in  physiological 
chemistry.  A  third  assistant  should  preferably  be  a  man 
skilled  in  zoological  and  general  biological  enquiry.  All  as- 
sistants should  be  skilled  in  microscopical  and  general  histologi- 
cal technique. 

"At  a  later  date  a  larger  expert  staff  will  probably  be  found 
necessary.  In  the  compilation  of  statistics  the  services  of  a 
trained  actuary  would  be  almost  essential  for  a  time. 

"The  enquiry  must  start  at  selected  points  and  be  allowed 
to  develop  itself  in  the  hands  of  those  conducting  it  along  those 
lines  which  the  experience  accumulated,  will  in  natural  course 
dictate.  The  proceedings  must  therefore  be  cautious,  and  con- 
ducted on  the  very  widest  basis.  At  present  we  possess  no 
knowledge  which  justifies  limiting  the  enquiry  in  any  special 
direction,  but  no  reasonable  line  of  special  enquiry  should  be 
discouraged. 

"The  scope  at  the  outset  being  so  very  wide,  the  work  should 
primarily  be  directed  to  attempting  to  define  the  field  of  legiti- 
mate enquiry,  and  within  the  shortest  time  possible  attempting 
to  focus  the  efforts  on  a  rational  research  for  the  causal  factor 
or  factors.     This  limitation  may  best  be  obtained  within  a  rea- 


20  THE    CANCER    PROBLEM 

sonable  period  by  following  out  systematically  various  lines  of 
enquiry  at  the  same  time : — Statistical,  histological,  chemical ; 
pertaining  to  cancer  in  various  human  races,  animals,  plants 
(  '(),  and  with  consideration  of  all  alleged  causes — heredity, 
race,  climate,  soil,  etc.,  and  also  the  reputed  increase  of  cancer. 

"2.  Recommendations  Bearing  on  Special  Lines  of  En- 
quiry Which  May  Be  Divided  into  Statistical,  Ex- 
perimental, ETC. 

^'Statistical. 

'The  proper  study  and  interpretation  of  the  returns  of  the 
Registrar-General  should  be  augmented  by  special  enquiry 
directed  by  the  central  body,  because  the  special  statistics 
already  compiled  and  commented  on,  and  especially  those  of 
the  German  and  Dutch  Cancer  Committees,  and  those  relating 
to  Massachusetts,  have  not  yet  brought  to  light  evidence  free 
from  ambiguous  interpretation,  nor  have  they  the  value  which 
presumably  would  attach  to  the  similar  compilation  based  on, 
the  widely  divergent  races,  regions,  isolated  communities,  etc., 
which  would  come  within  the  scope  of  the  present  enquiry,  com- 
prising as  it  will  the  whole  British  Empire. 

"The  compilation  of  statistics  would  have  to  be  conducted 
along  the  soundest  lines,  and  with  regard  to  all  conditions 
which  may  be  supposed  to  favour  the  occurrence  of  malignant 
disease  in  man  and  animals. 

"Any  scheme  drawn  up  should  be  submitted  to  a  statistical 
expert  for  approval. 

"A  sufficiently  extensive  statistical  enquiry  may  be  expected 
to  lead  to  the  accumulation  of  facts  helping  to  decide  whether 
any  form  of  disease  comprised  under  the  term  'malignant'  is 
communicable  from  one  individual  to  another.  It  may  further 
be  of  help  in  determining  the  direction  enquiries  as  to  the  cause 
or  causes  are  to  take. 

"Owing  to  the  time  it  will  take  to  get  together  the  mass  of 
important  evidence,  which  is  waiting  to  be  collected  in  different 
parts  of  the  globe,  I  would  suggest  that  early  steps  be  taken 
to  organise  this  collection. 

"I  would  divide  into  two  great  classes  those  to  be  relied  upon 
for  the  immediate  collection  of  the  information  sought,  viz., 
those  voluntarily  assisting,  and  those  who  can  be  enlisted  in  the 
service  through  the  different  government  offices  and  various 
local  authorities. 

"It  will  thus  be  necessary  at  an  early  stage  to  ascertain  how 


HISTORY  21 

far  the  Local  Government  Board,  India  Office,  Colonial  Office, 
etc.,  town  and  county  councils,  and  other  authorities  having 
medical  or  veterinary  officers  in  their  services  would  be  in- 
clined to  assist  the  enquiry. 

^'Those  voluntarily  assisting  would  be  essentially  the  staffs 
of  hospitals  and  general  practitioners.  A  direct  appeal  to  each 
institution  and  individual  seems  desirable  in  order  to  direct 
attention  to  the  special  points  on  which  definite  information 
is  wanted. 

"To  avoid  misapprehension,  secure  uniformity,  intelligibil- 
ity, and  ready  classification  of  the  information  obtained  from 
such  divergent  sources  as  isolated  Crown  colonies,  town  and 
county  communities,  etc.,  definite  questions  should  be  asked. 
These  being  intended  to  elicit  from  distinct  sources,  both 
similar  and  different  kinds  of  information,  it  would  be  neces- 
sary to  draw  up  the  various  subjects  of  enquiry.  In  re- 
gard to  this  matter  advice  might  well  be  sought  from  the 
German  Cancer  Committee,  who  have  already  some  experience 
of  it. 

"In  the  interval  that  may  elapse  before  the  return  of  these 
enquiry  forms,  arrangements  would  have  to  be  made  for  the 
classification  and  interpretation  of  the  returns  under  the  com- 
bined direction  of  a  trained  statistician  and  a  director  or  other 
medical  official. 

"Importance  of  Co-operation  in  Experimental  Work. 

"In  order  to  obtain  the  co-operation  of  skilled  workers  who 
would  carry  on  special  parts  of  the  investigation  at  their  own 
laboratories,  etc.,  it  would  be  necessary  to  arrange  both  for 
grants  to  them  for  their  expenses,  and  for  honoraria  for  their 
work.  There  are  many  who  might  thus  be  encouraged  to 
assist  the  enquiry  by  undertaking  special  work  on  suggestions 
given  to  them  by  the  central  body,  e.  g.,  those  who  wish  to  use 
their  work  for  the  purpose  of  a  graduation  thesis  at  a  Uni- 
versity. 

"Of  course,  any  work  of  this  nature  may  be  performed  in 
any  laboratory,  the  only  condition  being  that  the  worker  is 
fully  qualified  to  undertake  the  work  proposed,  and  that  any 
control  or  suggestion  on  the  part  of  the  central  body  would 
be  permitted  by  the  chief  of  the  laboratory  in  which  the  work 
is  being  done.  In  order  to  emphasise  this  side  of  the  enquiry, 
circulars  would  have  to  be  directed  to  all  institutions  likely  to 
afford  facilities  for  work  of  this  nature,  or,  to  provide  such 
workers.     The  importance  of  central  control  would  have  to  be 


22  THE    CANCER    PROBLEM 

emphasised,  and  the  necessity  for  avoiding  undue  overlapping 
brought  into  prominence. 

"Importance  of  Study  of  'Maligtmncy.' 

"The  causes  of,  or  changes  which  may  accompany,  or  be 
responsible  for,  spread  in  the  body  must  be  investigated  with 
especial  care.  The  study  may  indicate  the  means  by  which 
power  to  spread  may  be  removed,  or  may  point  the  way  to 
limitations  in  other  directions.  In  this  connection  only  the 
emaciation,  secondary  anaemia,  and  leukocytosis  have  received 
much  attention.  The  not  infrequent  occurrence  of  pig-mented 
moles,  warts,  etc.,  in  albino  and  other  animals  seem  to  offer 
favourable  conditions  for  a  much  more  extensive  iijvestigation 
into  the  occurrence  of  other  conceivable  phenomena.  Thus  the 
possibility  of  converting  innocent  conditions  into  malignant 
growths  may  be  studied,  and  the  importance  of  investigating 
the  possible  influence  of  internal  secretions,  by  means  of  the 
injection,  etc.,  of  emulsions,  watery  and  other  extracts,  fluids 
obtained  under  high  pressure,  or  by  means  of  a  gelatine  filter 
under  high  pressure  from  malignant  growths  must  not  be  lost 
sight  of.  The  study  by  recent  methods,  of  changes  in  the  serum 
and  other  fluids  in  cases  where  spread  is  occurring,  or  where 
an  'innocent'  tumour  has  become  malignant,  with  a  view  to  de- 
tecting there  the  presence  of  anything  of  the  nature  of  an 
immune  body,  in  Ehrlich's  sense,  must  receive  attention.  It 
is  impossible  to  express  any  opinion  on  the  likelihood  of  being 
able  by  these  means  to  ascertain  the  presence  of  factors  which 
may  cause  spread,  be  concomitant  with  spread,  or  have  really 
an  antagonistic  influence  on  spread. 

"Importance  of  properly  controlling  all  Bio-chemical  Enquir- 
ies in  order  to  avoid  fallacies  and  all  tendency  toward 
their  assuming  a  too  speculative  nature. 

"Owing  to  the  extreme  complexity  of  the  experimental 
methods  necessary  to  this  line  of  enquiry,  it  could  only  be  car- 
ried out  under  the  direction  of  one  familiar  with  the  methods, 
the  manifold  fallacies  likely  to  present  themselves,  and  the 
equally  numerous  control  experiments  necessary. 

"Granted  due  attention  be  paid  to  the  above  sources  of  error, 
purely  hypothetical  considerations  must  for  the  present  suffice 
to  suggest  the  following  lines  of  enquiry. 

"A  thorough  scrutiny  of  malignant  disease  in  the  light  of 
the  knowledge  which  has  been  recently  acquired  in  regard  to 


HISTORY  28 

haemolysis,  cytolysis,  cytotoxines,  immune-bodies,  and  the  mech- 
anism of  their  action,  etc.,  ought  to  be  undertaken. 

"The  following  special  lines  of  enquiry  also  suggest  them- 
selves : — 

"A  search  should  be  made  for  evidence  of  anything  aris- 
ing pathologically,  or  experimentally,  in  consequence  of  the 
prolonged  irritation  of  tissues,  or  the  existence  of  cancerous 
conditions.  Such  evidence  might  be  sought  for  in  the  existence 
of  anything  in  the  nature  of  excessive  waste  products,  modified 
alkalinity  of  fluids,  autolysines,  isolysines,  etc.,  such  as  it  may 
be  assumed  might  possibly  stimulate  local  or  general  vegetative 
activity,  or  give  rise  to  detectable  excess,  or  deficiency  of  any 
constituent  of  cells,  or  of  fluids.  Also  any  evidence  of  local  or 
general  irritation  arising  from  such  causes  should  be  sought. 

"An  endeavour  might  be  made  to  determine  if  the  chemistry 
of  the  normal  cell  shows  any  divergence  from  that  of  the  cancer 
cell  which  has  developed  from  it.  By  means  of  modern  meth- 
ods applied  to  the  albuminous  bodies,  ferments,  etc.,  it  might 
be  possible  to  determine  any  divergence  in  the  nature  of  the 
constituents  of  these  cells;  the  presence  or  absence  of  normal 
or  abnormal  constituents  might  be  sought  for. 

"Hofmeister  has  recently  pointed  out  the  large  number  of 
distinct  ferments  contained  in  any  one  cell  of  the  liver.  It 
would  be  interesting  to  ascertain  to  what  extent  these  ferments 
are  present  in  the  cells  of  malignant  disease  of  this  organ. 

"An  enquiry  might  be  instituted  to  determine  if  any  stimu- 
lation of  cells  can  be  made  to  lead  to  the  production  in  the 
latter  of  manifestations  of  activity  with  depression  of  the 
special  function  (secretion,  motile  phenomena,  etc.),  i.  e., 
without  calling  forth  what  is  regarded  as  the  special  function 
of  the  cells  stimulated. 

'^Classification   and    attempted    Experimental   Production    of 
'Cancer'. 

"In  regard  to  the  attempted  experimental  production  of  in- 
nocent and  malignant  new  growths  in  animals,  or  the  possi- 
bility of  setting  up  the  features  of  malignancy  in  benign 
growths,  it  may  be  well  to  repeat  some  old  experiments,  for 
example,  in  relation  to  embolism,  etc.,  where  the  results  ob- 
tained may  have  been  vitiated  by  the  conditions  under  which 
the  experiments  were  at  the  tirae  carried  out. 

"In  this  connection  the  possible  experimental  production  of 
'Petroleum  cancer'  and  'Sweeps'  cancer'  would  have  to  be 
borne  in  mind,  and  experiments  carried  out  on  a  very  wide 
series  of  differing  species  of  animals. 


24  THE    CANCER    PROBLEM 

"The  classification  of  different  forms  of  cancer,  if  properly 
carried  out,  might  lead  to  the  elimination  of  some  forms  which 
may  be  found  to  be  due  to  special  parasites  (as,  for  example, 
actinomycosis  has  been  eliminated),  and  to  the  separating  off 
of  what  may  be  found  to  be  special  types,  or  only  seeming 
cancer.  In  all  investigations  of  this  nature  full  and  detailed 
histological,  chemical,  bacterial,  or  other  parasitic  investiga- 
tions must  be  made  and  a  full  history  of  each  case  clinically 
recorded. 

"The  reputed  transplantation  of  cancer  into  wound  margins 
ought  to  be  specially  enquired  into,  with  a  view  to  the  impor- 
tant bearing  such  an  occurrence  would  have  on  other  trans- 
plantation experiments.  Such  transplantation  experiments 
should  only  be  carried  out  with  regard  to  the  special  species  of 
animal  in  which  the  original  growth  occurred,  and  the  special 
tissue  in  which  it  seemed  to  have  had  its  origin.  For  all  ex- 
periments of  this  nature  the  importance  of  the  assistance  of  a 
trained  veterinary  man  is  very  evident,  for  it  would  be  espe- 
cially necessary  to  exclude  the  possibility  of  previous  infection. 

"A  systematic  study  of  the  effects  of  persistent  irritation  of 
different  epithelial  surfaces  in  different  species  of  animals 
might  be  found  to  have  important  bearings.  In  this  category 
possibly  the  study  of  'Petroleum  cancer'  and  'Sweeps'  cancer' 
might  be  placed. 

"Those  engaged  in  post-mortem  examinations  should  be  en- 
couraged to  search  systematically  for,  and  record  all  evidence 
of  incipient  or  undetected  malignant  disease.  Such  an  investi- 
gation might  throw  much  light  on  the  internal  conditions,  e.  g., 
in  the  alimentary  canal,  which  in  themselves  may  perhaps  lie 
long  dormant,  and  in  the  end  become  malignant,  in  the  same 
way  as  other  conditions  on  the  surface  of  the  body  are  known 
to  do. 

"A  comparative  study  of  mitosis  and  vegetative  activity 
would  require  to  be  undertaken.  Such  an  investigation  would 
cover  not  only  mitotic  and  vegetative  activity  in  embryonic  and 
cancer  cells,  but  also  that  occurring  in  the  cells  in  benign 
tumours,  and  of  tissues  which  have  reverted  to  an  embryonic 
type  in  processes  of  repair,  and  with  consideration  of  that  over- 
production which  is  an  essential  feature  of  repair. 

"I  would  respectfully  submit  that  any  such  scheme  as  the 
foregoing  can  only  be  provisional,  and  has  been  drawn  up  in 
full  consciousness  of  the  difference  between  drawing  up  a 
scheme  on  paper  and  putting  the  same  into  practice.  I  do  not 
claim  that  this  hastily  drawn  up  scheme  is  adequate  to  cover 
the  whole  field  of  enquiry.     In  conclusion  I  would  point  out 


HISTORY  25 

that  the  investigation  must  necessarily  follow  the  lines  which 
accumulated  experience  will  dictate. 

"(Signed)     E.  F.  Bashford. 
"Edinbukgh,  October  24,  1902." 

Bashford  was  able  to  conclude  his  preface  to  the  Third  Re- 
port by  stating,  in  1908,  that  with  the  completion  of  this 
Report  all  the  points  raised  in  the  provisional  scheme  of  in- 
quiry drawn  up  for  the  Executive  Committee  in  October,  1902, 
have  been  submitted  to  investigation.  He  continued:  "The 
important  investigations  made  by  workers  elsewhere  and  also 
by  my  colleagues  in  the  laboratory  since  that  date,  have  nat- 
urally had  much  influence  on  the  conduction  of  the  work." 

The  investigations  of  the  Imperial  Cancer  Research  Fund 
continue  to  develop  along  the  wide  and  numerous  paths  they 
have  so  consistently  pursued.  A  most  important  aspect  of  its 
activities  has  been  the  extent  to  which  material,  in  the  form 
of  animals  bearing  transplantable  tumors,  has  been  distributed 
throughout  the  world,  and  the  welcome  independent  investi- 
gators have  been  given  to  conduct  their  own  work  in  its  labora- 
tories. Associated  with  Bashford  there  have  been  Murray 
(from  the  beginning),  Cramer,  Haaland,  Russell,  v.  Gierke, 
Da  Fano,  Woglom,  Medigreceanu,  Bowen,  Copeman,  Wake, 
Compton,  Bullock,  and  others. 

OTHER    CANCER    RESEARCH    INSTITUTIONS 

The  establishment  of  these  larger  schemes  has  naturally 
been  followed  by  other  developments,  notably,  in  1906,  by  the 
foundation  of  Czerny's  Samariterhaus  at  Heidelberg,  to  some 
extent  through  Czerny's  generosity  when  he  resigned  the  Uni- 
versity Chair  of  Surgery. 

A  large  and  Avell-equipped  institute  has  been  added  to  the 
Brompton  Cancer  Hospital,  London;  and  the  Royal  Cancer 
Hospital,  Glasgow,  has  a  laboratory  on  a  smaller  scale.  In 
Moscow,  for  some  years,  there  has  existed  the  Morosoff  Insti- 
tute. In  Dundee  a  special  cancer  laboratory  was  attached  for 
a  time  to  the  Royal  Infirmary,  and  g  imilar  provision  existed  for 
some  time  in  the  University  of  Liverpool. 

The  Austrian  Cancer  Committee  has  equipped  a  well-ap- 
pointed chemical  laboratory  in  Vienna;  and  in  Hamburg, 
Cologne,  and  Leipsic  special  laboratories  have  been  or  are 
about  to  be  attached  to  the  large  general  hospitals. 

In  Europe  the  most  recent  event  of  importance  in  this  move- 
ment has  been  the  opening,  in  the  presence  of  the  Kaiser,  of  a 


26  THE    CANCER    PROBLEM 

new  Institute  for  Experimental  Therapeutics  at  Dahlen,  Ber- 
lin, to  be  devoted  mainly  to  the  investigation  of  cancer  and 
tuberculosis. 

In  America,  we  note  as  most  important,  the  growth  of  the 
Cancer  Department  of  the  Rockefeller  Institute,  the  laboratory 
of  the  St.  Louis  Cancer  Hospital,  and  the  formation  of  the 
Crocker  Cancer  Fund.  In  considering  all  these  institutes  and 
laboratories  and  the  workers  who  have  enjoyed  their  excep- 
tional facilities,  it  must  not  be  forgotten  that  individual  work- 
ers in  laboratories  elsewhere,  for  example,  Jensen,  in  Denmark, 
and  Borrel,  of  the  Pasteur  Institute,  in  Paris,  have  exercised 
a  profound  influence  on  the  development  of  modern  cancer 
research. 

George  Crocker  Special  Research  Fund  at  Columhia  Uni- 
versity.— Among  the  more  recently  endowed  institutions  for 
cancer  research  is  the  George  Crocker  Fund.  This  endowment 
is  not  only  the  most  important  in  America,  but  its  capital  funds 
represent  the  largest  sum  appropriated  anywhere  in  the  world 
toward  the  investigation  of  the  disease.  While  the  work  of 
organization  has  been  proceeding,  the  money  available  has  not 
been  allowed  to  lie  idle.  It  was  decided  by  those  who  had  the 
matter  in  hand  ''that  the  money  could  best  be  expended  by 
making  gi'ants  to  special  workers  in  the  laboratories  of  the 
College  of  Physicians  and  Surgeons  and  of  the  Department  of 
Zoology  of  Columbia,  in  order  that  no  time  might  be  lost  and 
the  money  put  to  immediate  use."  In  1912  Professor  Francis 
C.  Wood  was  appointed  Director,  and  Dr.  William  H.  Woglom, 
Assistant  Director.  A  laboratory  has  been  erected  and  clinical 
connection  will  be  maintained  with  St.  Luke's  Hospital. 

The  Institute  for  Cancer  Research  attached  to  the  Charite 
Hospital,  Berlin,  founded  in  1902,  consisted  of  the  provision 
of  a  small  number  of  beds  and  a  small  laboratory  for  experi- 
ments on  animals.  It  was  originally  under  the  direction  of  v. 
Leyden,  and  with  him  were  associated,  among  others,  F.  Blum- 
enthal,  L.  Michaelis,  and  C.  Lewin.  Subsequently,  after  the 
death  of  v.  Leyden,  Professor  George  Klemperer  became 
Director,  Carl  Lewin  remaining  as  Assistant.  The  laboratory 
is  now  housed  in  a  separate  building  outside  the  Charite  in 
Luisenstrasse.  During  v.  Leyden's  directorship  he  himself 
strongly  upheld  the  parasitic  hypothesis  and  sought  to  utilize 
the  experimental  study  of  the  disease  in  its  support.  The  pub- 
lications from  his  Institute  were  influenced  by  his  views  in  the 
cases  of  both  Michaelis  and  Carl  Lewin.  Carl  Lewin  still  main- 
tains this  outlook  on  the  problem,  and  Klemperer  has  also 
recently  committed  himself  to  the  view  that  cancer  arises  from 


HISTORY  27 

outside.  More  recently  this  Institute  has  become  associated, 
through  Emil  Fischer,  with  the  search  for  some  chemical  sub- 
stance having  a  special  affinity  for  the  supposed  cancer  parasite 
or  for  the  cancer  cell :  in  other  words,  it  has  become  associated 
with  the  chemotherapy  of  cancer  as  inaugurated  by  von  Was- 
sermann. 

In  The  Royal  Prussian  Institute  for  Experimental  Thera- 
peutics, at  Frankfort-on-the-Main,  under  the  direction  of  Pro- 
fessor Ehrlich,  there  has  been  a  department  for  cancer  investi- 
gation since  1901.  Associated  with  Ehrlich  originally  was 
Sticker,  who  worked  with  the  so-called  venereal  tumors  of  dogs. 
Later  Apolant  has  been  connected  with  this  Institute,  and 
with  Ehrlich  has  published  numerous  histological  papers  on 
tumors  in  mice,  as  well  as  valuable  contributions  to  the  study 
of  immunity.  Moreschi,  who  has  also  worked  here,  confined 
his  work  mainly  to  feeding  experiments. 

Ehrlich's  scheme  of  inquiry  appears  to  be  entirely  along 
biological,  histological,  and  cellular  lines.  He  has  never  given 
any  indication  that  he  agreed  with  the  infective  views  origi- 
nally put  forward  by  Sticker  during  and  after  the  time  when 
he  was  one  of  Ehrlich's  colleagues.  He  has,  however,  given 
indications  that  he  attaches  importance  to  Cohnheim's  germinal 
rest  hypothesis  and  to  the  possible  influence  of  constitution. 

On  the  twenty-fifth  anniversary  of  the  foundation  of  the 
Pasteur  Institute,  November  15,  1913,  Roux  gave  a  resume  of 
the  activities  of  the  Institute.  He  pointed  to  the  fact  that  Bor- 
rel,  who  is  one  of  the  chiefs  of  a  department  there,  had  conse- 
crated himself  especially  to  the  study  of  cancer,  working  on 
the  basis  that  cancer  arises  from  the  outside  owing  to  the  ex- 
istence of  a  cancerous  virus.  Borrel  had  been  especially  im- 
pressed by  what  he  regarded  as  veritable  epidemics  in  certain 
breeds  of  mice.  Borrel  also  regarded  the  virus  as  being  prob- 
ably conveyed  to  cells  already  prepared  for  its  reception  in 
consequence  of  prolonged  irritation.  The  parasites  to  which  he 
attached  most  importance  were  various  forms  of  worms  and  the 
demodex.  With  Borrel  there  have  been  especially  associated 
Haaland  and  Bridre.  Haaland  subsequently  spent  a  short 
time  in  Ehrlich's  Institute,  and  after  a  transitory  stay  in  his 
native  country  (ISTorway)  was  for  over  three  years  an  Assistant 
to  the  Imperial  Cancer  Research  Fund  in  London,  which  he 
left  to  become  Director  of  the  Gade  Institute  in  Bergen. 

In  Paris  there  exists  the  "Association  Frangaise  pour 
I'Etude  du  Cancer."  The  work  of  the  Association  has  resolved 
itself  largely  into  the  holding  of  meetings  for  the  reading  of 
papers.    It  issues  the  "Bulletin  de  1' Association  Frangaise  pour 


28  THE    CANCER    PROBLEM 

rfitnde  du  Cancer,"  and  ^'La  Rovuo  dii  Cancer."     The  objects 
of  the  Association,  as  set  forth  in  its  statutes,  are: 

1.  The  carrying  out  and  publication  of  experiments  relative 
to  cancer. 

2.  The  organization  of  laboratories,  dispensaries,  hospitals, 
etc. 

3.  The  granting  of  honoraria  to  authors  of  works  worthy  of 
interest. 

This  Association  was  also  responsible  for  the  organization  of 
the  large  International  Conference  held  in  Paris  in  1910. 

Czerny's  Institute  in  Heidelberg  is  an  Institute  of  the  Uni- 
versity. It  is  known  as  the  Samariterhaus,  in  order  that  pa- 
tients may  not  fear  entering  a  cancer  hospital.  It  receives 
cancer  patients,  and  those  suspected  of  suffering  from  cancer 
and  all  other  tumors ;  they  are  treated  according  to  the  best  and 
latest  scientific  methods.  Attached  to  the  hospital  are  chemi- 
cal, experimental,  and  parasitological  departments.  Von  Dun- 
gern  and  von  Wasielewski  have  been  successful  directors  of 
the  laboratories.  Associated  with  them  has  been  Dr.  Richard 
Werner,  who  has  devoted  himself  particularly  to  statistical  in- 
vestigations. Czerny's  hospital  has  become  mainly  identified 
with  attempts  to  supplement  surgery  by  other  means — for  ex- 
ample. X-rays  and  fulguration.  Practically  all  the  non-surgical 
measures  which  have  recently  been  put  forth  have  been  tested 
in  the  wards  of  his  hospital,  where  a  combination  of  treatments 
has  also  been  given  full  trial. 

In  1912  the  American  Association  for  Cancer  Research, 
which  is  affiliated  with  the  International  Association  for  Cancer 
Research,^  came  into  existence.  The  purpose  of  the  Association 
is  to  further  the  research  and  spread  of  the  knowledge  of  can- 
cer. It  has  held  several  meetings  at  which  a  large  number  of 
scientific  communications  have  been  made. 

COMPARISON    OF    METHODS    OF    INVESTIGATION 

From  the  preceding  accounts  of  the  beginnings  of  the  more 
notable  efforts  in  different  countries  to  elucidate  the  mysteries 
of  cancer,  it  will  have  become  evident  that  the  methods  adopted 
have  been  widely  divergent. 

The  German  Committee  was  originally  in  essence  a  society 
for  the  reading  and  discussion  of  papers  on  cancer,  by  an  as- 
semblage of  experts,  through  whose  influence  special  statistics 

*  At  a  meeting  of  the  Council  of  the  American  Association  for  Cancer 
Eesearch,  at  Toronto,  April  9,  1914,  it  was  voted  that  this  association  with- 
draw from  its  relationship  with  the  International  Association  for  Cancer 
Eesearch. 


HISTORY  29 

on  the  subject  (over  and  above  the  national  statistics)  were 
compiled,  and  under  the  influence  of  the  opinions  of  the  major- 
ity of  the  committee,  w^ho  held  that  cancer  was  an  infective 
disease  and  should  be  combated  as  such.  In  short,  the  method 
employed  was  that  of  settling  subjects  of  scientific  discussion 
and  regulating  the  conducts  of  investigation  by  a  majority  vote. 

In  the  case  of  Roswell  Park's  scheme  for  the  conduct  of  the 
ISTew  York  State  Laboratory,  and  that  of  Foulerton  for  the 
Middlesex  Hospital,  the  original  aim  of  investigation  was 
frankly  declared  to  be  the  better  utilization  of  clinical  ma- 
terial ;  and,  in  the  case  of  the  Middlesex  Hospital,  the  possible 
bearing  of  some  lines  of  inquiry  on  the  national  statistics  was 
not  forgotten. 

The  plan  of  investigation  drawn  up  by  Bashford  for  the 
Cancer  Research  Fund  was  of  much  wider  scope,  and  placed 
the  investigation  at  once  upon  a  wide  comparative  basis — 
pathologically,  statistically,  and  experimentally,  as  regards  dif- 
ferent races  of  mankind  and  animals.  If  the  share  which  the 
German  Committee  had  in  attaching  a  cancer  department  to 
the  Charite  in  Berlin  and  to  Ehrlich's  Institute  in  Frankfort 
be  excluded,  Bashford's  is  the  only  one  of  the  larger  schemes 
in  which  a  sharp  separation  of  human  patients  from  the  devel- 
opment of  the  study  and  experimental  investigation  of  cancer 
in  animals  was  fully  considered  and  provided  for. 

INSTITUTIONS    WHICH    COMBINE    CLINICAL    AND 
EXPERIMENTAL    WORK 

All  these  schemes  have  now  departed  to  a  great  extent  from 
their  original  form,  owing  to  development  along  lines  of  their 
ovni,  associated  with  the  results  which  their  several  plans 
yielded,  together  with  the  influence  exerted  by  the  general 
progress  of  the  investigations.  Since  their  initiation  there 
have  sprung  up  other  important  centers,  such  as  Czerny's  In- 
stitute in  Heidelberg,  the  Research  Institute  of  the  London 
Cancer  Hospital,  and  others,  in  which  the  attempt  is  made  to 
combine  clinical  work  on  the  disease  in  man  with  experimental 
study  of  cancer  in  animals.  Both  the  l^ew  York  State  Insti- 
tute and  the  Harvard  University  Commission  have  added  a 
small  amount  of  special  hospital  accommodation  to  their  labora- 
tories. 

RESEARCH    DEPARTMENT,    NEW    YORK    SKIN    AND 
CANCER    HOSPITAL 

The  cancer  research  work  of  the  'New  York  Skin  and  Cancer 
Hospital  has  been  in  progress  since  1904,  when  the  author  first 


30  THE    CANCER    PROBLEM 

became  connected  with  the  institution.  It  was  primarily  clini- 
cal. As  the  surgical  work  rapidly  progressed,  the  immense  field 
for  research  investigation  in  connection  with  it  became  more 
and  more  evident,  and  it  was  not  long  before  a  well-equipped 
pathological  laboratory,  with  a  skilled  pathologist  in  charge, 
was  added  to  the  cancer  department. 

The  research  work  was  given  direction  partly  in  consequence 
of  an  offer,  through  the  hospital,  of  a  cash  prize  to  be  awarded 
to  anyone  who  might  discover  a  cure  for  cancer.  Such  a 
volume  of  "cancer  cure"  correspondence  w^as  precipitated  upon 
the  writer,  as  Secretary  to  the  Research  Department,  that  it 
soon  became  evident  that  there  should  be,  in  this  country,  an 
institution  like  the  Middlesex  Hospital  Cancer  Department, 
London,  in  which  proposed  agents  and  methods  for  the  treat- 
ment of  cancer  might  be  "tried  out." 

The  first  definite  research  work  of  this  character  was  the 
trial  of  the  Enzyme  method,  generally  known  as  the  "Trypsin 
Treatment."     This  is  reviewed  briefly  in  Section  IX. 

Of  this  test,  the  Lancet,  October  9,  1909,  p.  1079,  under  the 
caption,  "The  Enzyme  Treatment  of  Cancer,"  said:  "Unde- 
terred by  the  discredit  into  which  the  methods  of  some  of  its 
exponents  had  brought  the  theory,  Dr.  Wm.  Seaman  Bain- 
bridge,  the  author  of  this  report,  has  fulfilled  his  undertaking 
to  give  the  treatment  a  fair  trial,  both  in  operable  and  in  inop- 
erable cases.  Many  of  the  patients  have  been  followed  to  their 
homes,  and  nurses  provided,  after  leaving  the  hospital,  while 
everything  possible  has  been  done  to  make  the  clinical  and 
pathological  observations  complete.  The  list  of  patients  and 
the  account  of  the  results  given  by  Dr.  Bainbridge  are  records 
of  the  miserable  failure  of  the  treatment,  but  they  are  monu- 
ments of  industry  which  will  be  of  service  in  the  interests  of 
sufferers  from  cancer.  .  .  .  The  negative  result  of  the  investi- 
gation is  to  be  regretted,  but  the  courageous  persistence  in  its 
conduct  in  the  face  of  discouragement,  and  the  care  with  which 
the  tests  have  been  carried  out  in  all  particulars  by  Dr.  Bain- 
bridge for  the  New  York  Skin  and  Cancer  Hospital,  may  serve 
as  a  model  to  other  institutions." 

The  final  recognition  of  the  useful  object  fulfilled  by  the 
"Trypsin  Test,"  made  it  possible,  financially,  to  launch  the  Re- 
search Department  on  a  really  creditable  basis.  At  the  present 
time  six  Research  Fellows  are  giving  their  services,  in  full  or 
in  part,  to  the  work,  with  fair  remuneration. 

In  addition  to  the  treatment  of  cancer  by  the  usual  surgical 
measures,  the  work  of  the  Research  Department  of  the  New 
York  Skin  and  Cancer  Hospital  is  fourfold : 


HISTORY  81 

(1)  The  care  of  advanced  cases — those  which  are  usually 
considered  "inoperable."  In  a  large  proportion  of  instances 
these  patients  represent  the  end-results  of  treatment  by  various 
so-called  "cures,"  and  many  more  have  been  the  subjects  of 
one  or  more  surgical  procedures.  They  may  all  be  said  to  be 
hopeless,  so  far  as  cur©  is  concerned,  but  much  may  yet  be  done 
to  relieve  suffering,  to  prolong  life,  and  to  make  their  remain- 
ing days  comfortable.  Not  only  are  the  patients  themselves 
often  cared  for  in  a  more  satisfactory  manner  than  is  possible 
in  their  homes,  but  their  friends  and  relations  are  spared  many 
of  the  distressing  circumstances  attendant  upon  the  care  of 
victims  of  cancer  in  the  last  stages. 

(2)  The  clinical  application  of  surgical  and  non-surgical 
methods  of  treatment  which,  from  time  to  time,  are  proposed, 
and  which  seem  to  warrant  a  thorough  trial.  This  includes  the 
various  bio-therapeutic  agents. 

Among  the  various  methods  of  treatment  which  have  been 
and  are  being  efficiently  tested,  may  be  mentioned  the  employ- 
ment of  Arterial  Ligation  in  the  treatment  of  advanced  cancer 
(see  Section  XI,  Chapter  2),  Fulguration  (de  Keating-Hart), 
Electrocoagulation  (Doyen),  Thermopenetration  (Nagel- 
schmidt),  and  Thermoradiotherapy  (de  Keating-Hart).  (See 
Section  X,  Chapter  2.) 

(3)  The  careful  study  of  the  blood,  urine,  and  other  body- 
fluids  of  cancer  patients,  and  of  the  structure  and  classification 
of  the  neoplasms  removed.  Each  case  is  studied  from  the  vari- 
ous points  of  view,  and  detailed  records  made  of  all  findings. 

(4)  The  education  of  nurses  and  internes  in  the  actual 
care  of  cancer  cases,  and  the  contribution  to  the  general  cam- 
paign of  education  by  the  dissemination  of  literature,  by  clini- 
cal lectures,  and  by  operative  clinics.     (See  Section  XIV.) 

The  combination,  in  the  hospital,  of  the  dermatological  with 
the  cancer  departments  is  an  important  feature  of  the  institu- 
tion. An  opportunity  is  thus  afforded  for  the  comparative 
study  of  cases,  particularly  those  in  which  skin  lesions  are  mis- 
taken for  cancer,  and  vice  versa. 

With  the  clinical  facilities  of  the  hospital,  and  an  increas- 
ingly efficient  research  department,  the  ISTew  York  Skin  and 
Cancer  Hospital  may  be  said  to  occupy  the  position  of  a  cancer 
"clearing  house"  for  this  country. 

As  in  the  case  of  the  New  York  Skin  and  Cancer  Hospital, 
no  doubt  many  other  special  and  general  hospitals  have  devoted 
great  attention  to  utilizing  their  opportunities  for  clinical  in- 
vestigation. Thus  there  has  developed  a  sharp  contrast  between 
purely  clinical  investigations  and  those  which  are  purely  ex- 


32  THE    CANCER    PROBLEM 

perimental,  or  attempts  at  a  compromise  by  combining  the  two. 
The  question  naturally  arises  which  of  the  three  courses  is  the 
most  advisable,  and  in  considering  the  answer  it  is  well  to 
emphasize  that  there  is  no  mutual  exclusion  of  clinical  and 
experimental  work.  The  one  is  the  complement  of  the  other, 
and  the  question  resolves  itself  simply  into  a  consideration  of 
the  circumstances  under  which  they  may  be  best  conducted, 
separately  or  combined.  This,  it  may  be  pointed  out,  is  quite 
a  different  proposition  from  the  question  considered  later,  of 
whether  or  not  it  is  advisable  to  urge  increased  hospital  pro- 
vision for  cancer  patients. 

THE     POSSIBILITIES     OF     CLINICAL     AND     EXPERIMENTAL    WORK 
AND    THE    UTILITY    OF    COMBINING    OR    SEPARATING    THEM 

The  present  point  of  view  with  reference  to  the  possibilities 
of  clinical  and  experimental  work  and  the  utility  of  combining 
or  separating  them,  may  be  reviewed  as  follows : 

1.  There  are  hospitals  where  only  clinical  or  surgical  in- 
vestigations can  be  made,  i.  e.,  each  operation  can  be  regarded 
in  the  light  it  sheds  in  advancing  knowledge  of  the  disease  or  of 
surgery.  There  can  be  no  doubt  that  in  the  past  surgery  has 
enormously  advanced  knowledge  of  the  mode  of  origin,  prog- 
ress, and  nature  of  cancer,  but,  as  with  purely  microscopical 
(histological)  investigations,  progress  is  now  stayed.  Such 
hospitals  can  assist  investigation  by  efforts  at  elucidating  the 
problems  of  metabolism  and  biochemistry,  which  conceivably 
lie  at  the  foundation  of  much  of  the  mystery  of  cancer.  They 
will  finally  determine  when  a  reliable  treatment  has  been 
found. 

2.  There  are  hospitals  where  clinical  and  surgical  work  is 
combined  with  pathology,  but  experiments  on  animals  are 
barred.  This  has  no  advantage  over  institutions  of  the  first 
class,  except  that  "living  pathology,"  as  it  has  been  described, 
is  combined  with  morbid  anatomy,  and  accurate  statistics  of  the 
causes  of  death  are  obtainable,  which  it  is  hoped  will  some  day 
demonstrate,  in  many  cases,  that  the  disease  had  been  removed 
and  that  death  was  not  from  cancer. 

3.  Hospitals  of  the  first  and  second  types,  in  which  ex- 
periments are  permitted.  In  such  hospitals,  unless  the  finances 
are  specifically  assig-ned  to  patients  and  to  animals,  experi- 
mentation is  handicapped  by  want  of  funds,  because  humanity 
and  sentiment  are  always  making  claims  for  provision  for 
patients  or  for  additional  beds  for  more  patients. 

4.  The  investigation  of  cancer  may  be  entirely  separated 
from  the  obligation  to  treat  it.     Thus  money  may  be  devoted 


HISTORY  33 

entirely  to  investigation  without  humanitarian  scruples.  This 
form  of  research  has  been  developed  to  the  highest  pitch  in  the 
case  of  the  Imperial  Cancer  Research  Fund,  which  has  no 
specific  connection  with  any  particular  hospital.  The  arrange- 
ment does  not  imply  that  the  workers  are  barred  from  access  to 
clinical  material;  on  the  contrary,  they  have  had  in  the  past 
equal  access  to  all  the  hospitals  in  London,  and  to  as  many  in 
the  provinces  as  was  practicable,  in  connection  with  clinical 
and  pathological  statistics  bearing  upon  diagnosis.  In  the 
future,  should  occasion  arise,  the  same  connections  could  be 
established  again,  and  certainly  would  be  were  a  scientifically 
verified  cure  discovered. 

The  purely  scientific  arguments  against  increasing  hospital 
accommodation,  on  the  plea  that  it  would  give  increased  facili- 
ties for  research,  have  been  set  forth  by  Bashford,^  who,  it  will 
be  noted,  pays  a  tribute  to  the  important  role  which  hospital 
investigation  has  played  in  the  past. 

"Before  1900,"  he  says,  "the  mere  desire  to  take  by  assault 
the  impregnable  fortress  within  which  the  mysteries  of  cancer 
were  concealed,  had  been  the  incentive  to  an  enormous  expen- 
diture of  human  energy.  To-day,  reflection  on  the  nature  of 
these  efforts  reveals  how  ill-advised  many  of  them  were;  but, 
apart  from  the  marvelous  developments  of  surgery,  there  are 
two  other  notable  exceptions,  viz. :  (1)  the  efforts  to  provide 
comfortable  housing  and  adequate  medical  care  for  those  be- 
yond surgical  relief  from  cancer;  and  (2)  the  effort  to  demon- 
strate the  direct  descent  of  the  cancer  from  what  had  been 
previously  well-behaved,  normal  tissues  of  the  individual  af- 
flicted. 

"The  proper  housing  and  the  medical  care  of  hopeless  cases 
of  cancer — which  must  not  be  confounded  with  the  equipment 
necessary  for  surgical  treatment,  or  for  investigation — remains 
as  laudable  a  form,  of  philanthropic  effort  to-day  as  it  was  when 
the  pioneer  charity  of  the  kind  was  established  at  the  Middle- 
sex Hospital  in  1Y92.  But  it  is  justifiable  for  sentimental 
reasons  only,  and  also  only  if  it  be  borne  in  mind  that  it  is  as 
impracticable  as  it  would  be  improvident  in  the  highest  de- 
gree, to  attempt  to  provide  such  accommodation  for  each  of  the 
25,000  persons  who  die  annually  from  cancer  in  England  and 
Wales.  If  the  money  so  expended  in  the  past  had  been  devoted 
to  research  work  purely,  it  would  have  relieved  or  cured  the 
sufferings  of  millions,  where  it  has  merely  smoothed  the  way 

1  Bashf ord,  E.  F. — ' '  The  Obligations  Imposed  on  the  General  Practi- 
tioner by  the  Development  of  the  Experimental  Investigation  of  Cancer," 
The  Practitioner,  November,  1911,  p.  337. 


34  THE    CANCER    PROBLEM 

to  the  death  of  hundreds;  for,  in  the  present  state  of  knowl- 
edge, this  is  all  that  such  provisions  can  do,  and  it  has  been  a 
proper  restriction  of  its  activity  in  the  past.  This  statement  is 
not  made  for  lack  of  sympathy  with  the  suiferings  of  the  25,000 
who,  denied  the  privileges  of  the  one  or  two  hundred  housed 
in  cancer  asylums,  die  in  poorhouse  infirmaries,  or  at  home 
surrounded  by  relatives,  needlessly  afraid  of  what  may  be  the 
consequences  of  their  daily  intimate  association  with  the  af- 
flicted ;  but  is  made  because  of  the  conviction  that  some  portion 
of  the  imperfect,  but  improved,  knowledge  made  available  for 
treatment  only  in  recent  years  might  have  been  made  applic- 
able long  ago. 

''The  enormous  improvements  in  the  surgical  treatment  of 
cancer  are,  with  the  single  exception  of  Lister's  unique  ser- 
vices, the  result,  not  of  the  revolutionary  conceptions  of  genius, 
but  of  the  labour  of  those  who  had  no  opportunity  to  avail  them- 
selves of  experimental  methods,  because  such  methods  had  not 
entered  upon  a  rational  phase.  Conclusions  which  experiment 
speedily  arrived  at,  i.  e.,  within  three  years,  afforded  decisive 
proof  of  the  validity  of  all  that  lies  at  the  basis  of  the  early 
surgical  removal  of  the  disease,  although  this  treatment  has 
been  deduced  from  much  more  laborious  and  more  prolonged 
investigations,  and  from  observations  often  admitting  only  of 
ambiguous  interpretation.  This  treatment  had  to  contend  with 
all  possible  forms  of  reasonable  and  unreasonable  opposition; 
but  it  held  its  own,  and  the  subsidiary  part  played  by  experi- 
ment in  justifying  it  will  be  related  later. 

"To  attempt  to  provide  cancer  asylums  for  all  cancer  pa- 
tients is  impracticable,  because  the  disease  is  not  usually  recog- 
nized sufficiently  early  to  make  it  of  use  in  treatment.  It  is 
also  impracticable  on  the  score  of  expense,  and  it  would  be  an 
improvident  expenditure  of  money  and  energy.  It  is  im- 
provident mainly  for  two  reasons.  First,  as  will  be  explained 
later,  the  cancer  from  which  any  individual  suffers  has  been 
demonstrated  experimentally,  within  quite  recent  times,  to  be 
dangerous  to  the  individual  in  which  it  arises,  and  only  rarely, 
if  at  all,  and  even  then  only  in  special  experimental  conditions 
in  the  lower  animals,  dangerous  to  any  other  individual.  With 
proper  care  as  regards  cleanliness,  all  that  is  offensive  to  those 
associated  with  a  cancer  patient  can  be  avoided.  The  disease 
is  neither  infective  nor  contagious  in  the  popular  sense  of  the 
words,  and  the  actual  presence  at  the  present  moment  in  Eng- 
land and  Wales  of  some  50,000  persons  suffering  from  cancer, 
constitutes  no  danger  to  those  with  whom  they  are  brought  in 
contact,  and  no  national  peril;  still  less  is  it  a  national  obliga- 


HISTORY  35 

tion  to  separate  them  from  the  enjoyment  of  surroundings  they 
perhaps  love  the  more  because  of  the  knowledge  that  it  will  not 
be  for  long. 

^'Secondly,  it  has  become  demonstrably  improvident  to  pro- 
vide cancer  asylums  for  inoperable  cases,  because  of  the  little 
that  can  be  done,  once  the  resources  of  surgery  have  failed  or 
been  refused,  and  of  the  certainty  of  a  lethal  end;  but  more 
particularly  it  would  be  improvident  to-day,  as  a  means  of 
helping  future  sufferers,  because  the  limitations  imposed  by 
studying  the  disease  solely  in  the  human  subject  brought  the 
advance  of  knowledge  to  a  standstill.  Without  new  guidance 
all  has  been  learned  that  can  be  learned  from  the  study  of  the 
final  stages  of  its  clinical  course,  and  by  post-mortem,  micro- 
scopical, bacteriological,  and  chemical  examinations.  But  even 
if  this  standstill  in  the  advance  of  knowledge  had  not  been  the 
real  cause  for  the  widespread  public  alarm  at  the  end  of  the 
nineteenth  century,  how  could  adequate,  or  even  any,  financial 
assistance  whatsoever  be  devoted  justifiably  to  research  work 
in  any  hospital,  whether  receiving  cases  still  within  surgical 
aid,  or  specially  devoted  to  the  reception  of  cancer  patients 
hopelessly  incurable,  unless  the  money  so  employed  was  spe- 
cially ear-marked  for  this  specific  purpose  ?  The  number  of 
patients  requiring  relief  would  exhaust  the  greatest  financial 
resources.  The  utter  hopelessness  of  the  practitioner  in  deal- 
ing with  inoperable  cases  of  cancer  is  the  principal  vindication 
of  the  need  for  resort  to  experiment  on  animals. 

"Whilst  the  investigation  of  cancer  must  have  as  its  ultimate 
goal  the  successful  treatment  or  prevention  of  the  disease,  it 
by  no  means  follows  that  this  goal  will  be  attained  by  directly 
going  for  it,  and  the  treatment  of  cancer  must,  because  of  our 
ignorance,  be  sharply  distinguished  from  its  investigation. 
From  the  standpoint  of  what  is  practicable  and  politic,  treat- 
ment and  experimental  investigation  are  also  wisely  maintained 
apart.  Especially  is  this  the  case  when  the  exigencies  of  in- 
vestigation necessitate  resort  to  indirect  methods,  e.  g.,  to  ex- 
periments on  animals,  or,  in  other  words,  to  a  frank  confession 
of  helplessness  when  restricted  to  the  study  of  cancer  in  man. 
This  segregation  is  also  important  where  the  association  of 
treatment  with  investigation  is  apt  to  oblige  the  investigator 
to  depart  from  the  only  true  path  to  follow  in  the  pursuit  of 
knowledge,  and  to  compel  him  to  search  directly  for  results 
surmised  to  be  capable  of  immediate  application  to  the  treat- 
ment of  the  human  subject.  At  the  beginning  of  1900,  with 
the  exception  of  one  or  two  very  small  foundations,  no  money 
whatsoever  was  available,  either  at  home  or  abroad,  for  the 


36  THE    CANXER    PROBLEM 

specified  object  of  encouraging  any  kind  of  investigation  of 
cancer,  and  the  medical  profession,  as  a  whole,  were  ignorant 
of  the  fact,  or  actually  denied,  that  cancer  occurred  in  animals." 

SUMMARY 

The  manner  in  which  scientific  inquiry  is  conducted,  and 
the  results  speedily  spread  broadcast  throughout  the  world, 
demonstrate  how  each  center  of  investigation  is  being  influ- 
enced by  what  goes  on  in  all  the  others.  It  is  also  easily  evi- 
dent that  at  any  one  important  center  a  special  line  of  investi- 
gation will  be  better  carried  out  than  at  all  the  others ;  indeed, 
the  special  investigations  with  which  the  important  centers 
have  come  to  have  their  names  associated  fully  demonstrates  this 
point.  Clearly  recognizing  this,  the  best  investigators  do  not 
permit  themselves  to  be  diverted  from  the  paths  they  have 
struck  out  by  the  results  arrived  at  in  laboratories  not  their 
own.  In  the  same  way  revolutionary  discovery  made  clinically 
would  react  on  the  laboratory  worker,  and  the  latter  would 
likewise  at  once  influence  the  clinician.  Hence  it  appears  that 
the  two  are  best  separated  at  present.  Where  there  is  an  abun- 
dance or  superabundance  of  clinical  material,  attention  should 
not  be  diverted  by  an  inadequate  experimental  department, 
and,  vice  versa,  the  experimenter  should  not  have  the  "bogey" 
of  hunting  directly  for  a  cure  ever  before  his  eyes,  by  being 
brought  into  direct  contact  with  the  human  sufl"ering  he  is 
powerless  to  relieve  because  he  is  neither  a  surgeon  nor  a 
physician. 

This  is  a  matter  quite  distinct  from  the  question  of  providing 
increased  hospital  accommodation  for  cancer  patients,  espe- 
cially for  incurable  sufferers,  as  discussed  in  Section  XIII.  As 
a  means  of  promoting  the  investigation  of  the  disease,  its  disad- 
vantages have  been  set  forth  above  in  a  quotation  from  Bash- 
ford,  but  we  shall  again  consider  it  from  the  standpoint  of  its 
being  a  philanthropic  duty  until  such  time  as  science  relieves 
the  community  of  this  burden  of  suffering. 

The  creation  of  committees  or  funds  and  the  provision  of 
laboratory  accommodation  is  in  the  end  of  little  avail,  as  the 
course  of  events  in  the  last  ten  years  has  shown.  Except 
where  the  right  workers  have  been  secured  and  allowed  to  de- 
velop their  ideas  untrammeled,  little  or  no  progress  has  been 
made,  and  laboratories  in  local  centers  have  come  to  an  end 
because  local  support  ceased  to  be  obtainable  for  investigations, 
the  slow  progress  of  which  the  layman  could  not  comprehend. 


SECTION    II 

GENERAL   DISTRIBUTION 

Cancer  was  formerly  believed  to  be  confined  to  the  human 
species,  and  to  the  higher,  or  so-called  civilized,  races.  vSavage 
and  other  primitive  races  were  thought  to  be  exempt.  With  the 
inauguration  of  modern  cancer  research,  investigations  have 
tended  to  convince  many  that  malignant  tumors  may  arise, 
under  certain  circumstances,  in  any  multicellular  animal  or- 
ganism. Some  students  of  comparative  pathology  have  gone 
so  far  as  to  express  the  opinion  that  an  etiological  similarity 
exists  between  abnormal  budding  in  the  vegetable  world  and 
tumor-formation  in  the  animal  kingdom. 

Environment  and  nutrition  have  been  suggested  as  dominant 
factors  in  the  production  of  these  pathological  outgrowths  alike 
in  plants,  lower  animals,  and  human  beings.  It  has  been 
claimed,  for  example,  that  in  many  recorded  instances  of  vege- 
table tumors,  the  trees  or  other  plant  subjects  bearing  them 
lived  under  adverse  circumstances,  as  in  low,  damp  places, 
where  the  ground  was  constantly  watered  by  sewage-contami- 
nated streams,  the  plants  being  thus  improperly  nourished. 

It  has  been  thought  that  animals  living  in  their  native  sur- 
roundings, those  to  which  their  organisms  have  become  thor- 
oughly adapted,  are  presumably  very  little  subject  to  tumor- 
formation.  Transplanted  to  a  different  environment,  as  to  a 
zoological  garden,  or  to  a  domesticated  existence,  the  liability 
to  new  growths  was  said  to  increase.  This  contention  is  diffi- 
cult of  proof,  figures  upon  the  subject  being  comparatively 
meager. 

In  like  vein  it  is  argued  with  reference  to  man.  In  his 
primeval  condition,  with  the  simple  life,  which  differs  but 
little  from  that  of  the  lower  animals,  he  has  been  thought  to  be 
very  little  subject  to  new  growths,  particularly  to  those  of  a 
malignant  character.  With  changed  environment,  it  is  claimed 
by  some,  there  comes  an  increase  in  susceptibility  to  cancerous 
diseases,  this  susceptibility  becoming  more  marked  as  civiliza- 
tion develops ;  in  other  words,  as  environment  changes. 

37 


38  THE    CANCER    PROBLEM 

A  study  of  the  general  distribution  of  cancer  and  other 
tumor  formations  is  interesting  and  not  without  profit.  So 
long  as  the  essential  cause  of  malignant  neoplasms  remains  un- 
known, it  may  be  hoped  that  investigation  of  the  occun-ence 
of  such  neoplasms  will  aid  in  giving  direction  to  the  search 
for  etiological  or  causative  factors. 

The  ste-ady  increase  in  the  number  of  deaths  recorded  from 
cancer  among  intelligent  and  well-to-do  members  of  society  is 
calling  forth  added  interest  in  the  so-called  "direct  method"  of 
studying  the  disease.  This  method  involves  investigation  of 
the  ethnological  and  geographical  distribution  of  cancer,  a 
close  insight  into  questions  of  racial  predisposition,  social  con- 
ditions, habits  of  life,  diet,  climate,  soil,  and  the  various  other 
factors  which  from  time  to  time  have  been  proposed  as  con- 
tributory causes  in  the  production  of  malignant  new  growths. 

1^0  disease,  with  the  possible  exception  of  tuberculosis,  has 
called  forth  more  study  from  the  statistical  point  of  view  than 
has  cancer.  From  all  parts  of  the  world  figures  and  other  data 
have  been  compiled  concerning  the  incidence  of  the  disease, 
and  more  and  more  each  year  attention  is  being  directed  to  the 
ethnological  and  geographical  conditions  which  may  have  some 
possible  connection  with  its  occurrence. 

It  is  proposed  in  this  section  to  discuss  the  ethnological  and 
geographical  distribution  of  cancer  in  man,  to  give  some  of  the 
more  recent  statistical  and  other  data  collected  by  various 
authorities  concerning  the  occurrence  of  malignant  and  non- 
malignant  neoplasms  in  lower  animals,  and  to  review  briefly 
some  of  the  findings  concerning  cancer-like  formations  in 
plants.  The  enormous  mass  of  material  of  this  character  which 
has  been  published  will  be  drawn  upon  for  such  facts  or  theories 
as  seem  to  throw  most  light  upon  the  etiology  of  the  disease, 
and  for  those  most  significant  as  regards  prophylaxis,  diagnosis, 
and  treatment. 

At  the  present  stage  of  development  of  the  cancer  problem, 
it  is  impossible  to  reach  definite  conclusions  from  such  infor- 
mation, although  inferences  may  be  drawn,  subject,  of  course, 
to  modification  as  further  knowledge  is  obtained. 

Study  of  the  question  from  this  point  of  view,  more  and  more 
clearly  demonstrates  the  practically  world-wide  distribution  of 
cancer.  At  the  same  time  it  should  emphasize  the  fact  that 
there  is  undoubtedly  a  variation  in  the  frequency  with  w^hich 
cancer  is  recorded  among  different  races,  in  different  countries, 
and  in  different  localities  of  a  given  country.  Comparative 
investigations  also  tend  to  convince  the  careful  student  of  sta- 
tistical records  that  poverty,  filth,  and  squalor,  the  great  pro- 


GENERAL    DISTRIBUTION  39 

ducers  of  infective  diseases,  are  not  the  necessary  concomitants 
of  cancer.  Such  investigation  seems,  however,  to  emphasize 
the  view  that  simplicity  of  life  lessens  the  danger  of  the  disease. 
The  bearing  that  a  study  of  the  ethnological  and  geographical 
distribution  of  cancer  may  have  in  directing  experimental  work 
and  in  clearing  up  certain  ideas  concerning  the  pathology  of 
the  disease,  will  be  discussed  in  other  sections. 


CHAPTER   I 

BOTANICAL   DISTRIBUTION 

It  is  believed  by  many  students  of  comparative  pathology 
that  tumors  analogous  to  malignant  and  non-malignant  neo- 
plasms in  man  and  animals  may  be  found  in  vegetable  or- 
ganisms. iS[oel  ^  has  gone  so  far  as  to  hold  that  certain  "arbo- 
real cancers"  may  be  communicated  to  human  beings  and 
animals  by  contagion. 

A  distinction  is  made  by  students  of  plant  pathology  be- 
tween the  tumor  formations  which  result  from  abnormal  bud 
evolution,  and  which  are  alleged  to  be  analogous  to  cancers  in 
man  and  animals,  and  the  tumor-like  gall  formations  which  are 
due  to  the  action  of  parasitic  or  other  extrinsic  irritants. 
Those  who  still  hold  to  the  parasitic  theory  of  the  origin  of 
cancer  would  naturally  not  make  this  distinction. 

It  is  held  by  some  that  cancer  and  cancer-like  growths, 
whether  of  plants,  animals,  or  man,  are  due  to  changes  in 
nutrition  which  cause  altered  growth  and  impaired  develop- 
ment, the  fundamental  physiological  and  pathological  proc- 
esses being  the  same  in  plants  and  animals.  Others  have  as- 
sumed that  some  of  the  tumor  formations  (galls)  of  plants  are 
proof  of  the  parasitic  origin  of  cancer  in  man  and  animals. 

JSTotable  among  the  last-named  vegetable  "cancers"  are  the 
tumors  of  the  cauliflower  and  other  members  of  the  cabbage 
family,  known  in  the  German  as  "Kohlhernie,"  and  in  Eng- 
lish as  "club-root,"  and  "finger-and-toe  disease."  This  disease 
is  due  to  a  protozoan,  the  Plasmodiophora  hrassicce,"  and  is 
thought  by  some  upholders  of  the  parasitic  etiology  of  carci- 
noma to  be  analogous  to  the  proliferation  of  epithelial  cells  in 

*  Noel,  L. — ' '  Sur  la  topographie  et  la  contagion  du  cancer. ' '  ^ev.  des 
mal.  Cancereuses,  Paris,  1896-1897,  II,  pp.  137  and  201;  also:  These  de 
Paris,  1897. 

^"Finger-and-toe  disease,"  "  club- root, "  "hanbury,  "  "Kropf, " 
' '  Kohlhernie, ' '  as  the  disease  is  variously  called,  attacks  all  kinds  of  cab- 
bage, kale,  kohlrabi,  and  other  edible  cruciferse.  The  disease  was  first  re- 
corded in  Scotland,  in  1789.  It  is  now  distributed  in  all  places  where 
cabbage,  turnips,  and  allied  vegetables  grow  on  a  large  scale.  The  mal- 
formations which  characterize  the  condition  are  the  result  of  hyper- 
trophy of  the  host-cells  due  to  a  stimulus  exerted  by  the  Plasmodiophora 
hrassiccB. 

40 


BOTANICAL    DISTRIBUTION  41 

that  disease.  The  analogy  is  carried  further;  the  "cancer 
bodies"  described  in  human  malignant  tumors  are  supposed 
to  be  protozoa,  and  these  unicellular  organisms  are  considered 
to  be  the  cause  of  cancer.^ 

It  has  been  claimed  by  some  investigators  that  these  protozoa, 
in  spore  form,  are  found  in  the  cells  of  the  diseased  plants. 
After  experimentation,  some  authors  have  stated  that  these 
organisms,  inoculated  into  rats  and  guinea-pigs,  produce  nod- 
ules resembling,  in  some  cases,  large-celled  sarcoma,  endo- 
thelioma, or  granuloma,  but  not  producing  epithelial  prolifera- 
tion. Von  Tubeuf,^  on  the  other  hand,  considers  that  plant 
^'cancers"  cannot  be  compared  with  cancers  in  man.  Animal 
and  vegetable  parasites  or  frost  may  cause  tumor-formations 
in  plants.  His  experiments  with  the  inoculation  of  animals 
with  PlasmodiopJiora  hrassicce  produced  nothing  analogous  to 
cancer. 

Another  illustration  of  irritative  cell  proliferation  in  plants 
is  seen  in  tumors  due  to  abnormal  bud  evolution,  resulting 
from  fungus  or  parasitic  irritation,  of  which  the  "witches' 
broom"  is  an  example. 

The  point  of  infection  by  the  extrinsic  irritative  element  is 
the  starting  place  of  the  "witches'  broom."  The  "broom"  gen- 
erally originates  from  a  bud  which  has  been  infected  during 
the  previous  summer.  This  bud  presumably  produces  a  twig 
capable  of  abnormally  increased  growth.  The  original  leader 
shoot,  of  which  some  lateral  shoot  develops  into  a  "witches' 
broom,"  shrivels  and  dies,  the  hypertrophied  branches  seeming 
to  absorb  its  contents. 

William  G.  Smith,  Lecturer  on  Plant  Pathology,  University 
of  Edinburgh,  has  found  asci  (small  membranous  bags,  in 
which  the  spores  of  lichens,  fungi,  etc.,  are  inclosed)  of  a 
fungus  on  the  leaves  of  the  "witches'  broom"  so  commonly 
seen  on  the  birch  trees  of  Scotland,  Mites  are  also  supposed 
by  some  to  cause  these  abnormal  bud  formations, 

Erwin  F,  Smith,^  of  the  Bureau  of  Plant  Industry,  L^nited 
States  Department  of  Agriculture,  has  maintained  for  several 
years  that  the  crown  gall  of  plants  resembles  malignant  human 
tumors,  and  that  study  of  the  former  may  be  made  to  throw 

*  Nichols. — "Third  Keport  of  Harvard  Cancer  Commission,"  1905,  p.  79. 

^Von  Tubeuf. — "Ueber  Krebs  bei  Pflanzen,"  Verhandl.  des  Komites  fiir 
Erebsfarschung,  Heft  1,  p.  74,  Berlin,  1902;  also:  Deut.  med.  Woch.,  1902, 
Vereias-beilage  p.  96.  See  also:  von  Tubeuf  and  Smith — "Diseases  of 
Plants  Induced  by  Cryptogamie  Parasites,"   1897,  p.  524. 

^ ' '  The  Structure  and  Development  of  Crov?n  Gall :  A  Plant  Cancer. ' ' 
U.  S.  Department  of  Agriculture,  Bureau  of  Plant  Industry,  Bulletin  No. 
255,  June  29,  1912. 


42  THE    CANCER    PROBLEM 

light  upon  the  pathology  of  the  latter.  With  the  discovery  of  a 
tumor  strand  and  of  a  stem  structure  in  secondary  tumors  in 
leaves,  this  view  received  added  interest.  He  believes  that  the 
crown  gall  possesses  peculiarities  of  neoplastic  growth  which 
remove  it  from  all  ordinary  plant  diseases  and  which  place 
it  in  the  cp.tegory  of  the  true  tumors  (atypical  blastomas).  In 
other  wol'ds,  he  contends  that  ''crown  galls  are  to  all  intents 
and  purposes  cancers."  These  tumor-formations  in  plants 
have  been  found  to  be  due  to  a  schizomycete,  Bacterium  tumer- 
faciens,  Smith  and  Townsend.  The  bacteria  are  said  to  be 
located  inside  the  cells.  The  stimulus  of  the  presence  of  these 
organisms  causes  the  cell  to  divide  by  abnormally  throwing  it 
out  of  balance,  this  stimulus  probably  extending  to  many  sur- 
rounding uninfected  cells. 

Among  other  statements  in  his  resume  of  the  studies  made  by 
himself  and  his  coworkers  concerning  the  cro\vn  gall  Smith  says : 

''Crown  galls  occur  on  a  great  variety  of  plants,  but  not  al- 
ways on  the  crown;  any  part  of  the  root  or  shoot  is  liable  to 
attack." 

"They  are  all  of  parasitic  origin,  unless  the  one  on  the  beet 
studied  by  Jensen,  Reinelt,  and  Spisar,  in  Europe,  should 
prove  an  exception." 

"We  have  isolated  the  parasite  from  24  species  belonging  to 
14  families  of  phanerogams.  Some  species  have  resisted  in- 
fection." 

"The  infectious  nature  of  the  organism  isolated  has  been 
proved  by  hmidreds  of  inoculations  and  its  ability  to  produce 
galls  on  other  plants  than  the  one  from  which  it  was  isolated 
by  many  cross  inoculations." 

"The  parasite  has  been  shown  to  occur  not  only  in  the  pri- 
mary tumor,  but  also  in  the  secondary  tumors  and  in  the 
connecting  tumor  strand." 

"The  tumor  sends  out  roots  (tumor  strands)  into  the  normal 
tissues.  These  may  extend  for  some  distance  from  the  tumor — 
how  far  is  not  known." 

"In  the  substance  of  these  deep-lying  strands  secondary 
tumors  develop.  These  gradually  rupture  their  way  to  the 
surface." 

"The  secondary  tumors  tend  to  take  on  the  structure  of  the 
primary  tumor,  e.  g.,  if  the  latter  is  in  the  stem  and  the  former 
in  a  leaf,  the  secondary  tumor  shows  a  stem  structure." 

"The  development  of  this  disease  is  regarded  as  closely 
paralleling  what  takes  place  in  cancers  of  men  and  animals." 

"There  are  no  true  metastases  in  crown  gall,  but  this  does 
not,  to  our  mind,  militate  against  the  comparison,  for  whether 


BOTANICAL    DISTRIBUTION  48 

a  cancer  shall  be  propagated  by  floating  islands  of  tissue,  or 
only  by  tumor-strands,  appears  to  be  a  secondary  matter  de- 
pending on  the  character  of  the  host  tissues  rather  than  on  the 
nature  of  the  disease.  The  essential  element  is  the  internal 
stimulus  to  cell  division." 

It  goes  without  saying  that  investigators  who  have  not  sub- 
scribed to  the  parasitic  origin  of  cancer  fail  to  recognize  the 
analogy  which  to  Smith  and  his  coworkers  seems  so  patent. 
Notably  the  presence  of  the  parasites  in  Smith's  secondary 
growths  is  in  contradiction  to  the  way  in  which  secondary 
growths  arise  in  man.  Moreover,  Jensen  ^  has  described  tu- 
mors of  the  beet  which  he  was  able  to  transplant  so  that  a 
tumor  of  a  red  beet  grew  in  a  white  beet,  and  vice  versa;  but 
Jensen  could  not  find  any  parasitic  cause  for  these  growths. 

The  olive  is  particularly  subject  to  tumors  known  as  "olive 
knots,"  which  vary  from  the  size  of  a  pea  to  that  of  a  hazelnut. 
These  tumors  are  due  to  the  action  of  bacteria.  The  twig  on 
which  the  knot  or  gall  forms,  dies  above  the  gall.  The  willow, 
birch,  pine,  and  other  trees  are  subject  to  a  similar  disease. 
Certain  pines,  particularly  in  the  region  of  the  Alps,  are  espe- 
cially subject  to  these  twig-galls,  which  are  larger  than  those  of 
the  olive. 

Vegetable  tumors,  particularly  those  known  as  galls,  are 
regarded  by  some  students  of  plant  pathology  as  being  the 
result  of  an  excessive  local  cell  proliferation  initiated  by  the 
irritative  action  of  a  virus  of  insects  which  make  wounds  for 
the  purpose  of  depositing  in  them  their  ova.  Others  hold  that 
these  galls  result  from  the  activity  of  the  larva  after  it  has  been 
hatched,  and  not  from  the  sting  of  the  adult  insect. 

It  is  interesting  to  note  that  until  about  two  hundred  years 
ago  galls  were  supposed  to  be  of  purely  vegetable  origin,  and  the 
insects  in  them  were  thought  to  have  been  produced  by  spon- 
taneous generation.  Malpighi,  in  the  second  half  of  the  seven- 
teenth century,  was  the  first  to  show  the  insect  origin  of  galls. 

Calkins,^  discussing  the  suggested  analogy  between  vege- 
table and  animal  and  human  tumors,  says:  "The  advocates 
of  the  parasite  theory  believe  that  the  cancer  cell  became  a 
parasite  in  the  above  sense  [that  the  cancer  cell  is  a  parasite 
itself],  not  from  any  derangement  of  metabolic  processes,  nor 
from  any  vague,  hypothetical,  inherent  tendency  to  cellular 
anarchy,  but  because  of  susceptibility  to  the  poisonous  stimulus 

^  Jensen,  C.  O. — ' '  Von  Eehten  Geschwiilsten  bei  Pflanzen. ' '  Travaux  de 
la  2  Conference  Internationale  pour  l':&tude  du  Cancer,  1910,  Paris,  1911, 
p.  243. 

^Calkins.— "Protozoology,"  p.  209. 


44  THE    CANCER    PROBLEM 

of  some  parasite.  In  this  they  are  supported  by  the  facts  of 
gall  formation  in  phmts,  where  a  known  poison,  secreted  by 
insects,  stimulates  the  latent  division  energy  of  the  plant  cells, 
and  a  tumor  is  produced.  The  counter  argument,  so  often 
made,  that  such  abnormal  growths  are  nothing  like  cancer,  is 
certainly  true ;  the  analogy,  however,  is  not  with  the  form 
which  the  growth  assumes,  but  with  the  cell  which  is  stimu- 
lated to  divide  by  the  activity  of  a  parasite.  Among  other 
things,  the  gall  differs  from  the  cancer  cell  in  having  no  in- 
fectivity,  the  stimulus  not  being  continuous. 

"Another  analogy  is  drawn  from  the  great  tumor-like  growths 
in  certain  vegetables  (cruciferac),  due  to  the  presence  in  the 
root  cells  of  a  protozoon  parasite,  Plasmodiophora  hrassicrr. 
These  growths,  known  as  club-root,  hanburies,  fingers-and-toes, 
etc.,  are  highly  infectious,  and  are  frequently  a  serious  menace 
to  market  gardens.  The  organism  causing  the  tumors  pene- 
trates the  root  hairs  of  the  cabbage  or  other  allied  vegetables 
in  the  form  of  a  minute  ameboid  flagellate  (Woronin,  1878, 
Prowazek,  1905).  Two  or  more  may  enter  the  same  cell, 
where,  immersed  in  the  fluid  cytoplasm,  they  lose  their  flagella 
and  grow  into  larger  ameboid  organisms.  Later,  these  ameboid 
cells  fuse,  forming,  as  in  all  myxomycetes,  a  syncytium  or 
Plasmodium.  The  infected  cells  are  caused  to  divide  by  the 
presence  of  the  parasite,  the  infected  cells  thus  carrying  the 
disease-causing  germ,  which  in  itself  apparently  has  no  power 
of  migrating  from  cell  to  cell  (Prowazek,  1905).  After  a 
number  of  such  divisions  the  infected  cells  undergo  hyperplasia 
or  hypertrophy;  the  pressure  and  possibly  the  toxins  from  the 
organisms  cause  neighboring  cells  to  proliferate  until  large  ab- 
normal growths  result." 

Bland-Sutton,^  discussing  Cohnheim's  theory,  expresses  the 
belief  that  "tumor  germs"  actually  exist  in  the  body.  "The 
erratic  growth  of  such  undeveloped  portions  of  tissue  may  well 
be  illustrated  in  a  simple  way  by  examples  from  the  vegetable 
kingdom.  The  stems  of  trees  and  woody  plants  form  a  large 
number  of  buds,  most  of  which  grow  into  branches.  Some  of 
these  remain  undeveloped  for  a  time,  and  then,  instead  of  form- 
ing a  normal  branch,  they  grow  erratically,  and  form  a  swelling 
or  woody  tumour  of  irregular  shape,  which  may  attain  a  large 
size.  Such  a  tumour  of  a  tree  is  termed  a  xyloma.  The  bud- 
like character  of  such  woody  tumours  is  shown  in  an  interesting 
series  presented  to  the  museum  of  the  Royal  College  of  Sur- 
geons by  Mr.  Stephen  Paget.  From  some  of  the  tumours  buds 
have  grown  into  a  minute  branch.  Every  swelling  on  a  tree, 
'  Bland-Sutton. — ' '  Evolution  and  Disease, ' '  London,  1890,  p.  241. 


BOTANICAL    DISTRIBUTION  45 

however,  is  not  a  woodj  tumour  or  xyloma;  many  are  due  to 
insect  bites." 

In  addition  to  the  vegetable  tumors  which  arise  in  conse- 
quence of  the  action  of  extrinsic  irritants,  other  manifestations 
of  abnormal  bud  evolution  are  said  to  result  from  intrinsic 
causes,  such  as  changed  or  abnormal  nutrition. 

Williams  ^  classifies  these  tumor-formations,  which  are  some- 
times placed  in  the  category  of  "malformations,"  under  the 
following  groups: 

1.  Circumscribed  woody  nodules  commonly  found  beneath 
the  bark  of  the  beech,  elm,  oak,  cedar,  holly,  and  other  trees. 
"Knauer"  is  a  term  commonly  applied  to  these  formations. 

2.  Continuous  tumors,  comparable  with  the  exostoses  of 
human  pathology,  and  appearing  as  woody  outgrowths  of  the 
trunk  or  branch. 

3.  Burrs,  "broussins,"  the  free  and  continuous  formation 
of  proliferous  buds,  shoots,  and  stunted  branches. 

Penhallow,  Macdonald  Professor  of  Botany,  McGill  Uni- 
versity, has  reported  an  interesting  instance  of  continuous 
tumor-formation.  The  tumor  was  twenty  feet  long,  and  hung 
free,  being  attached  at  the  upper  end  only.  There  was  nothing 
to  indicate  intermittent,  longitudinal  growth,  there  being  an 
entire  absence  of  rings  or  scars  to  mark  successive  periods  of 
development,  such  as  were  found  in  the  leaf  scars  and  nodes 
upon  young  branches  of  the  same  tree.  From  this  it  was  in- 
ferred that  the  entire  growth  took  place  within  one  season. 
The  tumor-formation  was  not  an  aerial  root,  such  as  is  found 
in  tropical  latitudes.  Penhallow  concludes  that  the  outgrowth 
had  its  origin  in  a  lesion  of  the  bark,  the  precise  nature  of 
which  could  not  be  determined.  Some  investigators  would  at- 
tribute this  to  an  extrinsic  irritative  stimulus,  whereas  others 
would  consider  it  due  to  an  intrinsic  cause,  as  changed  or  ab- 
normal nutrition.  The  same  might  be  said  of  the  other  classes 
of  tumors  cited  by  Williams. 

SVIOCAIIY 

The  suggested  analogy  between  the  various  so-called  tumor- 
formations  in  the  vegetable  kingdom  and  benign  or  malignant 
neoplasms  in  the  animal  kingdom  has  not  been  established  by 
the  evidence  offered.  The  statement  that  "crown  galls  are  to 
all  intents  and  purposes  cancers,"  is  apt  to  be  misleading,  since 
it  presupposes  the  parasitic  origin  of  cancer — a  supposition  not 
established  by  indisputable  evidence. 

*  Williams.— "  The  Natural  History  of  Cancer,"   1908,  p.  120  et  seq. 


46  THE    CANCER    PROBLEM 

Biologists  as  a  whole  are  very  unwilling  to  draw  close  com- 
parisons between  the  higher  plants  and  the  higher  animals. 
The  continuous  growth,  which  is  characteristic  of  many  plants 
that  have  long  been  propagated  by  cuttings,  is  illustrated  in  the 
Lombardy  poplars,  spread  all  over  Europe  in  the  time  of  Na- 
poleon. These  trees  have  in  many  instances  reached  the  end 
of  life,  but,  by  making  fresh  cuttings,  new  trees  are  again 
grown.  So  that  there  seems  to  be  no  end  to  some  individual 
plant  organisms,  as  contrasted  with  the  definite  end  set  to  the 
life  of  all  higher  animals.  In  this  respect  the  propagation  of 
cancer  by  implantation  or  grafting  on  other  animals  must  be 
sharply  distinguished  from  the  grafting  of  plants,  since  the 
former  remains  a  single  tissue,  whereas  it  is  the  rule  for  vege- 
table grafts  to  reproduce  the  features  of  the  entire  organism, 
to  produce  flowers  and  seed. 


CHAPTER   II 
ZOOLOGICAL    DISTRIBUTION 

Despite  the  many  difficulties  involved  in  the  study  of  the 
zoological  distribution  of  cancer,  much  interesting  material  has 
been  collected,  and  certain  lines  of  inquiry  have  been  very 
definitely  indicated.  Particularly  does  this  apply,  in  the  latter 
regard,  to  certain  of  the  mammalia  commonly  classed  as  do- 
mesticated animals,  as,  for  instance,  horses,  cows,  sheep,  dogs, 
cats,  pigs;  and  also  to  certain  others  not  usually  so  considered, 
yet  which  have  so  intimate  a  connection  with  domestic  life  as 
to  come  within  its  category,  such  as  tame  rats,  mice,  rabbits, 
and  guinea-pigs. 

The  study  of  the  zoological  distribution  of  cancer  has  estab' 
lished  beyond  further  question  the  fact  that  malignant  new 
growths  are  not,  as  was  formerly  held,  a  purely  human  affec- 
tion. It  has  shown,  as  Sir  John  MacFadyean  maintained — a 
view  which  Bashford  and  Murray  have  confirmed — that  all  the 
histological  types  of  malignant  new  growths  in  man  are  recog- 
nized in  domestic  and  wild  animals. 

Other  questions  which  have  been  elucidated  by  the  study  of 
cancer  in  animals,  and  which  will  doubtless  be  further  clarified 
as  these  investigations  progress,  are: 

1.  Influence  of  environmental  changes,  including  diet. 

2.  Influence  of  chemical  and  other  irritants. 

3.  Influence  of  heredity. 

4.  Age  incidence. 

5.  The  influence  of  use  on  organs — site  incidence. 

Influence  of  Environmental  Changes,  Inclnding  Diet. — Natu- 
rally enough,  domesticated  animals  and  wild  animals  living  in 
captivity  have  furnished  the  majority  of  known  examples  of 
cancer  in  the  zoological  world.  Among  the  latter,  however,  the 
disease  is  comparatively  rare,  doubtless  largely  owing  to  the 
fact  that  so  great  a  proportion  of  wild  animals  kept  in  captivity 
die  young,  and  hence  before  the  so-called  "cancer  age." 

With  regard  to  the  frequency  of  cancer  among  wild  animals 
living  in  their  native  habitat,  there  are  conflicting  opinions. 
Some  students  of  pathology  hold  that  among  such  the  disease 

47 


48  THE    CANCER    PROBLEM 

is  very  rare,  if  not  entirely  unknown,  while  others  claim  that 
it  has  been  fonnd  with  siifficient  frequency  to  indicate  that  it 
is  not  nneoninion. 

Bashford '  holds  that  the  discovery  of  malignant  new 
growths  in  wild  animals  depends  npon  the  relative  facilities 
which  exist  for  careful  examination.  He  cites,  in  this  connec- 
tion, two  instances  of  malignant  new  growths  in  fish  living  in 
a  state  of  natnre,  and  one  in  a  wild  mouse.  This  contention  is 
in  line  with  the  statement  that  "the  great  diversity  of  food, 
habit,  and  conditions  of  life  generally,  in  animals  in  which 
cancer  occurs,  shows  that  such  external  agencies  have  no  causa- 
tive influence." 

Other  investigators  by  no  means  subscribe  to  such  state- 
ments, but  hold  that  every  phase  of  the  study  of  the  occurrence 
of  new  growths  in  animals  is  a  verification  of  the  theory  that 
cancer  incidence  is  very  largely  dependent  upon  environmental 
changes  or  abnormalities. 

Influence  of  Chemical  and  Other  Irritants.-— Another  phase  of 
the  problem  which  has  acquired  enhanced  importance  in  conse- 
quence of  the  study  of  the  zoological  distribution  of  cancer,  is 
the  effect  of  chemical  and  other  irritants,  not  only  in  the  pro- 
duction of  the  disease,  but  upon  the  rate  of  development  in 
animals  already  affected.  This  subject  has  been  studied  par- 
ticularly in  fish,  and  especially  in  artificially  bred  fish.  It  is 
supposed  that  in-breeding  and  certain  chemical  properties  of 
water  induce  simple  goiter  which,  later,  undergoes  cancerous 
degeneration.  Most  of  the  mouse  tumors  found  among  those 
of  one  breeder  were  cancers  of  the  breast  in  old  females  long 
used  for  breeding  purposes,  the  breasts,  presumably,  being  sub- 
jected to  prolonged  irritation  in  the  suckling  of  so  large  a  num- 
ber of  offspring.  The  influence  of  chronic  irritation  in  the 
production  of  cancer  is  seen  in  the  so-called  "brand-cancer"  of 
cattle,  and  the  "horn-core"  or  epithelioma  at  the  base  of  the 
horn,  in  Indian  draught  animals. 

Influence  of  Heredity. — It  has  been  possible  to  subject  the 
question  of  the  influence  of  heredity  to  actual  experimental 
tests  in  studying  laboratory  animals.  Bashford,  and  especially 
Murray,  of  the  Imperial  Cancer  Research  Fund,  and  Tyzzer, 
of  the  Harvard  Cancer  Commission,  have  been  working  along 
this  line. 

Bashford"  says  on  this  subject:  "In  surveying  the  inci- 
dence of  cancer  in  the  vertebrate  kingdom,  one  has  been  struck 

^Scientific  Reports,  Imperial  Cancer  Eesearch  Fund,  No.  1,  1904,  p.  7. 
'"Heredity   and  Disease — Cancer   Heredity,"  Proc.   Roy.  Soc.   of  Med., 
London,  November  18,  1908,  Vol.  II,   Part  I,  R.  S.   M.,  p.   63. 


ZOOLOGICAL    DISTRIBUTION  49 

hy  the  fact  that  certain  forms  of  cancer  appear  to  preponderate 
in  different  classes.  It  is,  of  course,  obvious  that  the  incidence 
in  representatives  of  different  zoological  classes  must  differ, 
since,  e.  g.,  structures  peculiar  to  mammals  are  absent  in  other 
vertebrates.  But  if  we  consider  the  mammalia  themselves,  it 
appears  probable  that  some  species  are  very  liable  to  forms  of 
cancer  from  which  others,  even  nearly  allied,  are  relatively  or 
altogether  exempt,  as  illustrated,  e.  g.,  by  the  variations  in  the 
frequency  with  which  cancer  of  the  uterus  or  mamma  occurs. 
Cancer  of  the  breast,  so  common  in  the  human  female,  is  also 
common  in  the  mouse  and  dog,  but  practically  unknown  in  the 
cow,  which,  however,  suffers  quite  frequently  from  primary 
growths  of  the  liver  and  adrenal.  These  tendencies  are  so  con- 
stant that  it  is  difficult  to  escape  the  conclusion  that  they  depend 
on  innate  characters  which  are  hereditarily  transmissible,  and 
there  can  be  no  doubt  as  to  their  setiological  importance,  al- 
though we  cannot  penetrate  to  their  meaning. 

''Even  in  the  same  species  we  meet  with  similar  idiosyn- 
crasies, e.  g.,  in  the  greater  liability  of  the  grey  than  of  other 
horses  to  melanotic  sarcoma.  It  may,  of  course,  be  argued  that 
these  peculiarities  of  incidence  of  the  disease  are  determined 
by  peculiar  environment  or  by  the  use  to  which  the  organs  are 
put  in  different  species,  although  this  would  hardly  hold  for 
grey  as  contrasted  with  other  horses,  the  disease  in  question 
affecting  only  the  pigment-cells  of  the  skin.  If  we  compare 
the  tame  albino  mouse  with  the  wild  grey  mouse  the  incidence 
of  cancer  is  parallel  in  them,  although  the  two  varieties  live 
under  very  divergent  conditions;  therefore  the  liability  of  the 
mouse  to  carcinoma  of  the  mamma  appears  to  be  due  to  an 
innate  tendency. 

''When  we  compare  the  large  natural  groups  of  vertebrates, 
or  even  the  species  of  the  mammalia,  the  grounds  on  which  we 
may  assume  that  differences  in  the  incidence  of  cancer  are 
innate  and  hereditarily  transmitted  appear  safe.  But  when 
we  come  to  compare  the  differences  in  the  incidence  of  cancer 
in  the  individuals  of  a  species  we  are  not  on  such  certain 
ground." 

From  these  observations  it  will  be  seen  that,  while  the  zoolog- 
ical distribution  of  cancer  has  throvsm  light  on  the  question  of 
heredity,  there  is  much  yet  to  be  learned  in  this  regard.  The 
subject  will  be  considered  more  in  detail  in  Section  III. 

Age  Incidence. — It  is  generally  conceded  that  in  animals,  as 
in  man,  cancer  is  more  liable  to  occur  in  aged  than  in  young 
subjects.  Inasmuch  as  the  length  of  the  life  cycle  varies 
greatly  in  different  species  of  animals  which  are  knovm  to  be 


50  THE    CANCER    PROBLEM 

subject  to  cancer,  it  is  presumed  that  the  latent  period,  the 
period  of  development  which  precedes  the  manifest  occurrence 
of  cancer,  likewise  varies. 

Bashford  has  pointed  out  that  because  domestic  animals, 
with  the  possible  exception  of  horses,  pet  dogs  and  cats,  are  not 
frequently  allowed  to  attain  old  age,  the  total  number  reaching 
the  most  favorable  age  for  the  development  of  cancer  is  small. 
So,  too,  with  wild  animals,  whose  struggle  for  existence  possi- 
bly permits  relatively  few  to  reach  old  age,  a  fact  which  might 
account,  in  part  at  least,  for  the  rarity  of  cancer  among  them. 
''A  comparative  study,"  he  says,  "of  the  age-incidence  of  can- 
cer among  domestic  and  wild  animals  of  varied  species  will 
certainly  give  comprehensive  information  on  the  relation  of  the 
incidence  of  cancer  to  the  rapidity  with  which  maturity  is 
attained.  Light  may  also  be  thrown  on  the  reasons  underlying 
the  higher  cancer-rate  of  late  life." 

Influence  of  Use  on  Organs — Site  Incidence. — The  site  inci- 
dence of  cancer  seems  to  vary  with  different  animals,  and  will 
be  included  under  the  discussion  of  the  occurrence  of  cancer  in 
specific  classes  of  subjects. 

DOG 

Among  domesticated  animals,  dogs  seem  to  lead  in  point  of 
frequency  of  occurrence  of  cancer.  Thus  Sticker  ^  tabulated 
1,312  cases  of  malignant  tumors  in  domestic  animals,  738  of 
which  were  in  dogs.  Of  60,471  dogs  which  were  treated  in  the 
Berlin  Thierarztlichen  Hochschiile  from  1886  to  1894,  2,871 
had  some  form  of  tumor,  1,154  of  which,  according  to  Frohner, 
were  cancerous.  Other  investigators  give  even  higher  percen- 
tages. The  dog  bears  out  what  has  been  said  concerning  age 
incidence.  The  disease  occurs  most  frequently  in  old  dogs,  a 
large  proportion  being  found  in  dogs  from  5  to  10  years  old. 
Malignant  tumors  in  dogs  under  2  years  of  age  are  said  to  be 
very  rare. 

Many  of  the  forms  of  malignant  new  growths  found  in  man 
are  also  to  be  found  in  dogs,  as  are  likewise  various  non- 
malignant  tumors.  Carcinoma,  of  the  malignant  tumors,  seems 
to  be  of  the  most  frequent  occurrence  in  the  canine  family,  the 
mamma  standing  at  the  head  of  the  list  of  the  sites  affected, 
this  region  being  involved  in  45  per  cent,  of  cases  (Sticker)  ; 
the  skin  in  21  per  cent. ;  anus,  21  per  cent. ;  liver,  3  per  cent. ; 
and  less  frequently,  kidney,  testis,  penis,  prostate,  eye,  bladder, 
vagina,  lung,  thyroid,  ovary,  etc.  (Williams,  p.  95). 

*  Sticker,  Anton. — "Ueber  den  Krebs  der  Thiere,  etc." — Arch,  fiir  klin. 
Chirurgie,  1902,  Bd.  LXV,  pp.  616,  1023. 


ZOOLOGICAL    DISTRIBUTION  51 

The  extreme  rarity  of  gastric  and  uterine  cancer  in  dogs  is 
interesting  from  a  biological  point  of  view.  The  relatively 
recent  development  of  the  uterus,  formed  by  fusion  of  both 
Miillerian  tubes,  produces  in  this  organ,  in  the  higher  animals 
as  well  as  in  man,  a  condition  of  great  instability  and  hence 
one  highly  susceptible  to  tumor-formations.^ 

The  relative  rarity  of  mammary  and  uterine  cancer  in  dogs, 
as  compared  with  man,  is  explained  by  Woods  Hutchinson  as 
due  to  the  fact  that  dogs,  unlike  human  beings,  seldom  live 
beyond  the  period  of  reproductivity.^ 

The  extreme  rarity  of  cancer  of  the  stomach  in  this  animal 
is  explainable  upon  the  basis  of  the  relative  stability  of  organs 
which,  from  an  evolutionary  point  of  view,  are  of  earliest 
development. 

CAT 

The  records  of  the  Veterinary  Pathological  Institute  of  Ber- 
lin show  that  of  34  cats  examined,  from  2  to  5.9  per  cent,  were 
affected,  and  various  individual  cases  of  cancer  in  cats  are 
reported  by  different  observers.  The  mammary  gland  and  the 
skin  are  apparently  most  liable  to  the  disease,  although  various 
other  parts  are  known  to  be  attacked. 

Spencer^  reported  a  case  of  carcinoma  involving  all  the 
mammary  glands  of  a  cat. 

Field  *  reported  a  scirrhus  of  the  mammary  gland  of  an 
old  cat,  and  a  mammary  cancer  with  metastases  in  lymphatic 
glands,  lungs,  heart,  stomach,  intestines,  uterus,  ovaries,  kid- 
neys, and  suprarenal  capsules.  Malignant  new  growths  of  vari- 
ous types  have  been  reported  in  different  localities  in  the  cat. 

HOUSES 

Horses,  mules,  and  asses  are  subject  to  malignant  new 
growths.  Of  215,037  horses  examined  at  the  "Hochschule" 
Veterinary  Clinic  in  Berlin,  according  to  Sticker,  only  103 
were  victims  of  malignant  tumors.  This  is  only  0.046  per 
cent.,  which  is  somewhat  at  variance  with  the  reports  of  vet- 
erinary journals  and  other  observers  (Williams,  p.  99). 

In  horses  the  parts  most  frequently  affected  by  primary  can- 
cer are  the  antrum  and  adjacent  naso-oral  cavities  (16  per 
cent.),  and  the  penis  (16  per  cent.),  the  kidney,  skin,  lungs, 

*  Hutchinson,  Woods. — ' '  Studies  in  Human  and  Comparative  Pathology, ' ' 
1901,  p.  257. 

2  Op.  cit.,  p.  263. 

^Spencer,  W.  G.— Trans.  Path.  Soc,  London,  Vol.  XII,  1890,  p.  40a. 

*  Field,   Eva  H. — ' '  A  Contribution  to   the  Study  of  Malignant  Growths 
in  the  Lower  Animals. ' ' — Jour.  Am.  Med.  Assn.,  1894,  Vol.  XXIII,  p.  982. 


52  THE    CANCER    PROBLEM 

and  pleura,  and  various  other  parts  being  affected  Avitli  rela- 
tively less  frequency.  With  the  horse,  as  with  other  animals, 
those  that  have  been  castrated  seem  more  prone  to  the  develop- 
ment of  malignant  neoplasms. 

BOVINES 

In  the  bovines,  cancer  is  common  in  the  liver,  stomach,  and 
adrenal,  according  to  the  figures  of  the  Imperial  Cancer  Re- 
search Fund.  Leo  Loeb  ^  has  stated  that  carcinoma  of  the 
caruncula  of  the  eye  is  common  in  a  certain  district  of  the 
L'nitetl  States.  The  rarity  of  cancer  of  the  udder  (mamma)  of 
the  cow  is  very  striking  in  vieAv  of  the  frequency  of  inflamma- 
tory processes  in  that  organ  and  the  extent  to  which  its  function 
is  abused. 

The  influence  of  chronic  irritation  in  the  production  of  can- 
cer, known  as  ''brand-cancer"  and  *'horn-core"  (epithelioma  at 
the  base  of  the  horn),  as  seen  in  draught  animals  in  India,  has 
already  been  mentioned. 

SWINE,    SHEEP,    AND    GOATS 

Swine,  sheep,  and  goats  are  very  rarely  reported  as  affected 
with  malignant  neoplasms,  probably  because,  as  a  rule,  they 
are  slaughtered  young,  before  the  cancer-age  begins. 

In  sivine,  the  kidney,  liver,  and  skin  are  the  sites  involved 
in  the  major  proportion  of  reported  cases,  although  various 
other  regions  may  be  affected. 

In  sheep,  the  liver  seems  to  be  a  chief  seat  of  primary  in- 
volvement. Among  other  sites  mentioned  as  being  affected  are 
the  maxillary  bone,  the  eye,  the  orbit,  and  the  lung. 

In  goats,  cancer  is  more  rarely  found,  judging  from  recorded 
cases,  than  in  any  other  domesticated  animal.  This,  however, 
may  be  explained  because  of  the  relatively  small  number  of 
goats  in  existence. 

WILD  ANIMALS  IN  THEIR  NATIVE  STATE  AND  IN  CAPTIVITY 

Tumors  have  been  found  in  the  following  wild  animals: 
lion,  tiger,  leopard,  bear,  rhinoceros,  hippopotamus,  porpoise, 
camel,  opossum  and  other  marsupials,  beaver,  whale,  mai*mot, 

*  Loeb,  Leo,  and  Johnson,  George. — ' '  On  Carcinoma  in  Cattle, ' '  Med- 
icine, April,  1900,  p.  286. 

Also:  Loeb. — "  Ueber  den  Krebs  der  Thiere, "  Arch,  fur  Min.  Chir., 
1903,  Bd.  LXX,  p.  845;  "Ueber  das  endemische  Vorkommen  des  Krebses 
bein  Tier,"  Centrlbl.  f.  Baiter.,  Bd.  37,  1904. 


ZOOLOGICAL    DISTRIBUTION  53 

kangaroo,  monkey,  wild  raccoon-dog,  deer,  rabbit,  rnouse,  rat, 
and  guinea-pig. 

Harlow  Brooks,^  Pathologist  of  the  New  York  Zoological 
Park,  says  concerning  the  occurrence  of  neoplasms  in  wild 
animals:  "True  neoplasms  in  wild  animals  which  live  under 
conditions  closely  approximating  the  natural  are  extremely 
rare.  This  is  true  of  relatively  pure  and  uncontaminated 
species." 

In  the  2,647  mammals  under  care  for  the  five  years  preced- 
ing this  communication  (1907),  but  a  single  case  of  true  neo- 
plasm occurred.  Of  these  animals,  744  came  to  complete  au- 
topsy without  a  single  new  growth  being  found,  with  the  excep- 
tion of  the  case  cited  by  Brooks,  which  is  detailed  below\ 
This  rarity  of  tumors  under  these  circumstances  may  be  ac- 
counted for,  in  part  at  least,  by  the  fact  that  such  animals  do 
not  live  to  an  advanced  age  (for  the  given  species). 

In  addition  to  these,  Brooks  reports  having  studied  a  con- 
siderable series  of  animals  secured  and  dissected  in  the  field 
by  himself  or  other  physicians.  Xot  a  single  case  of  neoplasm 
was  found  among  these  animals,  which  were  chiefly  iSTorth 
American  wild  ruminants. 

The  case  reported  Avas  that  of  a  white  raccoon-dog,  which 
had  been  an  inmate  of  the  park  for  over  two  years  before  it 
sickened  and  died.  It  was  captured  in  northern  Japan  and 
was  described  by  Director  Hornaday,  of  the  'New  York  Zoolog- 
ical Park,  as  a  new  species,  Nyctereutes  alhus. 

At  autopsy  the  animal  was  found  to  be  generally  emaciated, 
all  the  viscera  showed  the  efl^ects  of  malnutrition  and  anemia, 
consequent  upon  the  neoplastic  disease.  The  lower  two-thirds 
of  the  pelvic  and  abdominal  cavity  was  occupied  by  a  large 
retroperitoneal  mass  to  which  the  coils  of  intestines  were  ad- 
herent. The  tumor  apparently  originated  from  the  left  ovary, 
and  was  diagnosed  as  myxosarcoma. 

"Great  interest,"  quoting  from  Brooks,  "lies  in  the  discovery 
of  this  neoplasm  in  this  particular  animal,  not  only  on  account 
of  the  great  rarity  of  the  tumor,  but  chiefly  because  it  occurred 
as  the  only  example  of  tumor  formation,  in  an  animal  of  ques- 
tionable purity  of  species.  Many  zoologists  do  not  agree  that 
the  white  raccoon-dog  is  a  pure  species,  but  consider  it  a  'sport' 
albino,  or  the  result  of  mixed  parentage." 

"The  bearing  of  these  observations  on  the  general  question  of 
the  etiology  of  tumors  would  seem  to  tend  to  substantiate,"  he 

1  Brooks,  Harlow. — "Concerning  the  Occurrence  of  Neoplasms  in  WiM 
Animals,  with  the  Report  of  a  Case  of  Sarcoma  of  the  Ovary  in  Nycte- 
reutes Albus,"  Am.  Jour,  of  Med.  Sci.,  May,  1907,  Vol.  CXXXIII,  p.  769. 


54  THE    CANCER    PROBLEM 

continues,  "those  theories  attributing  neoplastic  formations  to 
perversions  of  cell  growth,  a  tendency  well  recognized  to  be 
more  frequent  in  animals  or  people  of  imperfect  development  or 
of  mixed  races,  or  such  as  live  under  more  or  less  artificial  en- 
vironment." 

BIRDS  * 
(Domesticated  Fowl) 

The  common  barnyard  fowl  is  said  to  be  the  frequent  subject 
of  neoplasms,  benign  and  malignant. 

Instances  of  tumor-formation  in  the  hen  and  cock  have  been 
reported  by  Bland-Sutton,  Ehrenreich  and  ]\Iichaelis,  Crisp, 
Birchmore,  Patterson,  Pick,  and  others.  Pe}i;on  Rous,  of  the 
Rockefeller  Institute,  has  lately  drawn  attention  to  the  great 
frequency  in  fowls  of  certain  connective  tissue  tumors,  which 
he  calls  sarcomata. 

The  goose,  also,  is  prone  to  such  growths,  a  number  of  in- 
stances being  on  record.  One  of  the  most  interesting  is  that 
of  a  "fibroid"  tumor  "as  big  as  a  large  lemon,"  which  occupied 
the  abdominal  cavity  of  a  goose,  supposedly  arising  from  the 
oviduct  or  intestine.  This  specimen  may  be  seen  in  the  Mu- 
seum of  the  Irish  College  of  Surgeons  (D.f.  56). 

Harrison  ^  reported  a  fibroid  tumor,  weighing  one  pound,  in 
an  old  goose  which  died  in  the  Clifton  Zoo. 

It  should  be  borne  in  mind  that  tubercle  causes  the  forma- 
tion of  large  tumor  masses  in  birds,  and  that  the  imperfect  de- 
scriptions published  of  many  of  these  "fibroid"  tumors  pre- 
vent their  being  accepted  without  reservation. 

WILD    BIRDS 

Pick  and  Poll  ^  have  stated  that  malignant  tumors  in  birds 
are  of  very  rare  occurrence,  yet  a  sufficient  number  have  been 
reported  to  show  that  wild  birds,  including  birds  of  prey,  come 
■within  the  category  of  susceptibility  to  this  class  of  disease. 

REPTILES    AND    AMPHIBIANS 

The  salamander,  tortoise,  lizard,  chameleon,  frog,  python,  and 
boaconstrictor,  are  some  of  the  members  of  these  orders  in 
which  malignant  and  benign  tumors  have  been  noted. 

•Third  Scientific  Eeport,  Imperial  Cancer  Eeseareh  Fund,  1908,  pp.  45- 
47;   Fifth  Report,  Harvard  Cancer  Commission,  p.  133. 

2  Harrison,  A.  G. — ' '  A  Study  in  the  Gardens  of  the  Clifton  Zoological 
Society,"  Bristol  Medico-Chirurgical  Journal,  1894,  Vol.  XII,  p.  285. 

'  Pick,  L.,  and  Poll,  H. — ' '  Ueber  einisre  bemerkenswerte  Tumorbildungen 
aus  der  Tierpathologie,  etc.,"  Berl.  Iclin.  Woch.,  1903,  Vol.  40,  pp.  518-572. 


ZOOLOGICAL    DISTRIBUTION  55 

Murray^  states  that  "Up  to  the  present  no  malignant  new 
growth  has  been  recorded  in  reptiles."  Bland-Sutton,^  how- 
ever, reports  a  case  of  medullary  cancer  in  a  python  which  had 
lived  in  the  Zoological  Society's  garden  for  fifteen  years.  A 
fibroma  in  the  stomach  of  a  python  was  described  by  Pet- 
tit.^  Koch^  reported  a  papilloma  of  the  occipital  region  in  a 
lizard. 

According  to  Murray  (loc.  cit.),  new  growths  from  amphibia 
are  very  limited  in  number.  "They  have,  however,  a  particu- 
lar interest  from  the  zoological  position  of  this  group,  and  the 
clearness  of  the  histological  picture,  due  to  the  large  size  of  the 
cells  of  these  animals  which  have  remained  the  classical  objects 
of  cytological  study,  especially  with  regard  to  cell-division,  ever 
since  Flemming  published  his  epoch-making  studies  on  indirect 
(mitotic)  cell-division  in  Salamandra  in  1882." 

Tumors  in  frogs  have  been  described  by  Eberth,  Pettit,  Pick, 
Smallwood,  Plehn,  and  others. 

FISH6 

It  has  been  suggested  by  Williams,  and  corroborated  by 
others,  that  fish  are  particularly  liable  to  infections  of  differ- 
ent kinds,  and  that  many  of  the  tumors  caused  by  sporozoa, 
mycoses,  bacteria,  etc.,  etc.,  may  be  mistaken  for  malignant 
tumors. 

It  has  been  well  established,  however,  that  tumors  of  un- 
doubtedly malignant  character  occur  in  large  percentages 
among  artificially  bred  fish.  Gilruth,  for  example,  showed  that 
thyroid  cancer  in  artificially  bred  salmon  trout  carried  off  in 
one  year  seven  per  cent,  of  the  fish  in  the  Auckland  Society 
Hatchery,  while  Bonnet  reported  three  thousand  cases  in  one 
hatchery  in  four  months.  Others  have  reported  "cancer  epi- 
demics" among  artificially  bred  trout. 

While  it  has  been  clearly  shown  that  fish  kept  under  artificial 
conditions  are  susceptible  to  cancer,  it  has  also  been  shown  fhat 
fish  living  under  natural  conditions  are  not  free  from  this 
disease. 

Murray,  Plehn,  Pick,  Jaboulay,  and  others  have  contributed 
to  the  investigations  concerning  cancer  in  artificially  bred  fish. 

'  Murray,  J.  A. — ' '  The  Zoological  Distribution  of  Cancer, ' '  Third  Scien- 
tific Eeport,  Imperial  Cancer  Eesearch  Fund,  1908,  p.  47. 

2  Bland-Sutton. — ' '  Tumors  in  Animals, ' '  Jour,  of  Anat.  and  Physi- 
ology (British),  Vol.  XIX,  1884-5,  p.  464. 

^  Pettit,  A.,  and  Vaillant,  L. — ' '  Lesions  stomacales  chez  un  Phython  de 
Sebo,"  Bull.  Mus.  Hist.  Naturelle,  Paris,  1902,  p.  301. 

*  Koch,  M.— Verhanndl.  d.  deut.  Gesselsch.  f .  Pathol.,  1904,  p.  136. 

^  See  General  Bibliography. 


56  THE    CANCER    PROBLEM 

Gaylord  and  Clowes,  likewise,  of  the  'New  York  State  Institute 
for  the  Studv  of  Malignant  Disease,  have  devoted  considerable 
attention  to  this  subject. 

In  connection  with  the  work  of  the  last-named  institution, 
it  is  interesting  to  note  the  "disquieting  information"  given 
out  by  the  United  States  Fish  Commission,  after  its  coopera- 
tion with  the  iS'ew  York  State  Cancer  Laboratory  in  the  inves- 
tigation of  thyroid  cancer  in  domesticated  fish.  The  following 
statement  is  contained  in  this  report :  "It  has  been  determined 
that  a  type  of  cancerous  affection  is  of  widespread  distribution 
among  domesticated  trout  and  their  offspring  planted  in  the 
streams.  Whether  this  disease  has  a  causal  relation  to  cancer 
in  human  beings,  or  whether  the  two  are  to  be  traced  to  even 
the  same  source,  is  a  matter  of  doubt,  but  the  annually  increas- 
ing mortality  from  cancer  in  man  and  certain  remarkable  coin- 
cidences in  the  geographical  distribution  of  the  disease  in  man 
and  fish  render  it  imperative  that  it  should  be  made  the  subject 
of  minute  inquiry.  The  matter,  therefore,  has  not  only 
economic  but  humanitarian  aspects,  and  the  consideration  of 
the  serious  character  of  the  latter  prompted  the  President  to 
submit  to  Congress  on  April  9,  1910,  a  special  message  advo- 
cating an  appropriation  of  $50,000  for  the  construction  and 
equipment  of  a  laboratory  adequate  to  enable  the  Bureau  to 
discharge  its  plain  obligations."  (This  appropriation  was  not 
made.) 

So  profound  an  impression  did  this  "disquieting  informa- 
tion" prove,  that  the  editor  of  the  Fishing  Gazette,  of  London, 
in  its  issue  for  March  11,  1911,  issued  a  "warning"  concerning 
cancer  in  trout  in  America.  "It  is  clearly  the  duty,"  he  said, 
"of  all  who  import  eggs  from  American  fish  hatcheries  to  ob- 
serve the  greatest  caution;  in  fact,  to  urge  their  Governments 
to  prohibit  the  importation  of  such  eggs." 

Naturally,  such  a  warning  from  the  editor  of  The  Fishing 
Gazette  had  its  effect;  in  fact,  so  great  was  this  effect  that  it 
bade  fair  to  paralyze  the  fishing  industry  of  Great  Britain, 
causing  such  alarm  among  people  in  general  that  fish  as  an 
article  of  diet  was  fast  falling  into  disuse.  At  this  juncture 
of  affairs,  the  editor  of  the  Gazette  appealed  to  Dr.  Bash- 
ford,  whose  reply  was  published  in  the  issue  for  April  8, 
1911.  Among  other  things  Dr.  Bashford  said:  "There  is  ab- 
solutely no  danger  of  the  communication  of  the  disease  from 
fish  to  man,  even  if  the  fish  were  not  cooked,  nor  do  I  think 
any  risk  is  implied  by  importing  the  eggs  of  the  Americayi 
SalmonidcB." 

This  quieted  the  fears  of  all  concerned,  the  fishing  industry 


ZOOLOGICAL    DISTRIBUTION  57 

resumed  its  usual  proportions,  and  the  public  returned  to  the 
consumption  of  fish  without  the  dread  of  cancer. 

Bashford/  who  has  had  a  very  extensive  experience  with 
these  so-called  cancers  of  the  thyroid  gland  in  trout,  had  his 
attention  again  directed  to  this  subject  by  Gilruth,  as  the  re- 
sult of  advertisements  which  he  inserted  in  the  Veterinary 
Record  in  1903.  Since  then  he  has  again  and  again  pointed 
out  that  these  enlargements  of  the  thyroid  in  trout  are  not  to 
be  regarded  as  epidemics  of  cancer  in  fish.  He  admits,  how- 
ever, that  cancer  may  develop  occasionally  on  goiter.  The  con- 
tinued reiteration  of  exaggerated  statements  regarding  this 
goitrous  disease,  and  its  presentation  to  the  public  as  if  it  were 
evidence  of  the  epidemic  occurrence  of  cancer  and  of  the  in- 
fective nature  of  malignant  new  growths,  are  greatly  to  be  dep- 
recated. 

Bashford  and  Murray  ^  stated  in  1905  :  "We  have  examined 
sixteen  cases  of  undoubted  malignant  new  growth  in  fish  alone, 
whereas  no  authentic  case  was  known  at  the  outset  of  these 
investigations.  .  .  .  1,500  growths  in  fish  have  been  reported 
to  us.  The  specimens  examined  have  included  fish  infested 
with  Nematodes  and  Cestodes,  bacterial  and  mycotic  infec- 
tions, malformations,  benign  tumours,  and  infective  conditions 
of  undetermined  aetiology.  In  trout,  tumours  of  the  branchial 
region  are  frequent  and  often  difficult  to  distinguish  from  true 
malignant  new  growths  because  the  thyroid  tissue  extends  dif- 
fusely along  the  branchial  arches  and  a  general  hypertrophy 
closely  simulates  a  primary  grovd;h  with  secondary  nodules." 

In  addition  to  Gaylord,  another  American  investigator, 
David  Marine,  has  done  very  careful  work,  the  result  of  which 
is  to  entirely  justify  the  attitude  which  Bashford  has  assumed. 
In  his  most  recent  paper  ^  he  summarizes  his  previous  experi- 
ence as  follows: 

"Investigations  ( 1 )  made  at  the  trout  hatchery  of  the  Bloom- 
ing Grove  Hunting  and  Fishing  Club  during  1909  and  1910, 
showed  that  all  the  fish  were  then  goitrous.  It  was  found  that 
the  thyroid  hyperplasia  began  in  the  fry  as  soon  as  feeding  was 
instituted,  and  advanced  overgrowth  was  present  at  the  fourth 
month  of  extra-oval  life ;  that  the  overgrowth  progressively  in- 
creased to  the  stage  of  clinical  detectability,  as  ascertained  by 
the  reddening  of  the  pharyngeal  floor  over  the  thyroid  area, 

1  First  Scientific  Eeport,  Imperial  Cancer  Eesearch  Fund,  1904. 

2  ' '  The  Statistical  Investigation  of  Cancer, ' '  Second  Scientific  Eeport, 
Imperial  Cancer  Eesearch  Fund,  London,  1905,  Part  I,  p.  49. 

'"Further  Observations  and  Experiments  on  Goitre  (so-called  Thyroid 
Carcinoma)  in  Brook  Trout  (Salvelinus  Fontiiialis),"  Jour,  of  Experi- 
mental Medicine,  Jan.   1,  1914,  p.  70. 


58  THE    CANCER    PROBLExM 

about  the  tenth  month  in  this  hatchery ;  that  visible  goitres 
usually  manifested  themselves  about  the  beginning  of  the  sec- 
ond year,  though  they  may  be  present  as  early  as  the  sixth 
month,  depending  on  the  favorableness  of  conditions  for  over- 
growth, and  progressively  increased  during  the  second  and 
third  years ;  that  older  fish  were  more  resistant  and  tended 
toward  spontaneous  recovery ;  that  the  water  in  which  these 
fish  lived  was  not  naturally  goitre-producing,  since  fish  living 
wild  in  the  stream  and  raceways  did  not  develop  thyroid  over- 
growth. 

"It  was  further  shown  that  overcrowding  and  overfeeding 
with  the  highly  abnormal  and  incomplete  diet  of  hog's  liver 
and  heart  were  the  major  gross  etiological  factors,  and  of  these 
the  food  was  the  more  important  factor  in  bringing  about  a 
fault  of  nutrition  which  stimulated  the  thyroid  to  compensatory 
overgrowth.  No  evidence  was  obtained  that  the  disease  was 
either  infectious  or  contagious,  or  that  a  direct  contagium 
vivum  could  account  for  the  phenomenon." 

He  concludes  his  paper  with  the  following  statements: 

"1.  Goitre  in  fish  is  a  non-infectious,  non-contagious,  symp- 
tomatic manifestation  of  a  fault  of  nutrition,  the  exact  bio- 
chemical nature  of  which  has  not  been  determined. 

"2.  Feeding  the  highly  artificial  and  incomplete  diet  of 
liver  is  the  major  etiological  factor  in  bringing  about  this  fault 
of  nutrition,  which  is  at  once  corrected  by  feeding  whole  sea 
fish. 

'^3.  Water  plays  no  essential  part  in  the  etiology,  transmis- 
sion, or  distribution  of  the  disease  in  the  fish  of  this  hatchery." 

It  will  thus  be  seen  that  the  statements  for  which  Dr.  Gay- 
lord  and  the  Xew  York  State  Laboratory  have  been  responsible, 
and  through  which  a  great  deal  of  needless  anxiety  has  been 
caused,  are  by  no  means  generally  accepted,  and  in  all  probabil- 
ity are  erroneous. 

MOLLUSKS 

Tumors  in  mollusks  are  presumably  very  rare ;  certainly  re- 
corded cases  are  not  very  numerous. 

Williams  ^  reported  having  found  one  tumor  in  700  mussels 
examined.  This  was  a  pediculated  tumor,  about  the  size  of  a 
hazelnut,  found  on  the  internal  aspect  of  the  left  pallial  lobe 
of  a  fresh-water  mussel  taken  from  a  private  fish-pond  at  Hen- 
don,  Middlesex.     He  considered  it  an  adenomyoma. 

*  Williams,  Joseph  W. — "A  Tumour  in  the  Fresh-water  Mussel  (Ano- 
donta  cyonea,  Linn.),"  Jour,  of  Anat.  and  Phys.,  Vol.  XXIV,  1889-90, 
p.  307. 


ZOOLOGICAL    DLSTRIBUTION  59 

Collinge,^  Honorary  Assistant  (hirator  to  the  Conchological 
Society  of  Great  Britain  and  Ireland,  found  two  instances  of 
tumor-formation  in  between  two  and  three  hundred  specimens 
of  mussels  examined, 

Ryder  ^  reported  the  finding  of  a  tumor  in  an  oyster,  the 
specimen  having  been  presented  to  him  by  Professor  Leidy. 
Keither  Leidy  nor  Ryder,  in  the  course  of  large  opportunities 
for  observation,  had  previously  encountered  such  a  specimen. 

SUMMARY 

The  evidence  is  conclusive  that  tumors,  benign  and  malig- 
nant, may  occur  in  any  multicellular  animal  organism.  This 
discovery  is  of  importance  to  the  student  of  comparative  path- 
ology and  to  the  investigator  of  cancer.  It  has  opened  the  way 
for  the  laboratory  investigation  of  many  problems  concerning 
cancer  which,  manifestly,  can  be  studied  only  with  difficulty  in 
the  human  subject.  The  significance,  for  example,  of  age  inci- 
dence, of  sex  incidence,  and  of  heredity,  the  transplantability 
of  cancer,  and  many  other  phases  of  the  subject,  have  been 
elucidated  in  an  important  and  remarkable  manner  in  conse- 
quence of  the  discovery  that  animals  other  than  man  may  suffer 
from  cancer.  Just  what  bearing  this  may  eventually  have  upon 
the  etiology  of  cancer  remains  to  be  seen.  It  certainly  has  not 
yet  established  any  essential  cause  of  the  disease.  It  has  not 
proved  that  man  may  acquire  cancer  through  the  consumption 
of  animals  afflicted  with  the  disease.  There  is,  therefore,  no 
element  of  alarm,  so  far  as  the  public  is  concerned,  in  the  fact 
that  no  higher  animal  is  quite  exempt  from  some  kind  of  tumor 
formation. 

However,  inasmuch  as  malignant  neoplasms  in  animals  are 
subject  to  degeneration  and  to  mixed  infection  with  organisms 
which  may  affect  human  beings,  the  careful  inspection  of  all 
animals  used  for  food  is  of  importance. 

^  Collinge,  Walter  E. — ' '  Note  on  a  Tumour  in  Onodonta  Cygnea,  Linn. ' ' 
lUd.,  1891,  Vol.  XXV,  p.  154. 

*  Ryder,  John  A. — ' '  On  a  Tumor  in  the  Oyster, ' '  Proc.  Acad,  of  Nat. 
Sciences,  April,  1887. 


CHAPTER   III 
GEOGRAPHICAL  AND   ETHNOLOGICAL  DISTRIBUTION 

Influence  of  Climate,  Soil,  Diet,  and  Habits  of  Life. — Inasmuch 
as  one  is  more  or  less  dependent  npon  another,  and  all  are  more 
or  less  interdependent,  these  factors  may  be  discussed  under 
one  head. 

It  has  been  stated  that  cancer  is  much  more  prevalent  in 
temperate  than  in  hot  or  cold  climates,  and  that  it  is  entirely 
absent  from  frigid  and  torrid  regions.  This  has  been  found,  by 
late  investigators,  to  be  untrue.  Those  who  have  studied  the 
subject  of  cancer  among  Esquimos,  for  example,  have  found  it 
to  be  not  entirely  absent  among  these  inhabitants  of  the  far 
north.  The  natives  of  the  South  Sea  Islands,  of  Equatorial 
Africa,  and  of  other  very  hot  countries,  who  were  formerly 
thought  to  show  an  almost  entire  absence  of  malignant  new 
growths,  are  now  known  to  possess  no  such  freedom.  In  Mex- 
ico, Central  America,  and  South  America,  cancer  is  said  to  be 
of  much  less  frequent  occurrence  than  in  North  America,  the 
frequency  of  its  occurrence  decreasing  with  the  distance  from 
the  equator. 

How  much  of  these  differences  is  traceable  to  a  lack  of 
observation  and  of  reporting  existent  cases,  further  study  alone 
must  determine. 

It  is  not  probable  that  the  climate,  per  se,  causes  whatever 
difference  there  may  be.  Some  investigators  hold,  however, 
that  it  plays  an  important  part  in  the  production  of  conditions 
of  life  which  seem  to  favor  the  development  of  cancer.  With 
regard  to  the  indirect  influence  of  climate  as  it  affects  diet  and 
habits  of  life,  it  has  been  pointed  out  that  the  greater  variabil- 
ity of  climate  in  temperate  countries  produces  a  more  rugged 
people  than  either  tropical  or  cold  regions,  and  that  this  vigor- 
ous life  calls  for  more  active  tissue  change,  which,  in  turn, 
creates  the  desire  for  more  stimulating  and  nutritious  food. 
This  supposedly  explains  the  larger  consumption  of  meat  in 
temperate  climates,  with  the  gi'eater  liability  to  dietary  ex- 
cesses, than  are  common  to  the  hibernating  natives  of  the  far 
north  or  to  the  frugal  and  simple-living  natives  of  the  far  south. 

60 


ETHNOLOGICAL   DISTRIBUTION  61 

India  is  often  cited  as  an  illustration  of  the  above  contention 
with  reference  to  the  frugal  life.  It  is  said  that  millions  of 
men  live,  marry,  and  rear  healthy  children  upon  an  income 
which  rarely  goes  above  two  shillings  (fifty  cents)  per  week, 
and  is  often  less.  It  has  been  estimated  that  the  42,000,000 
people  of  Great  Britain  consume,  in  food  and  drink  alone,  an 
amount  equal  to  the  whole  income  of  over  300,000,000  of  the 
people  of  India.  In  Great  Britain  the  average  weekly  income 
is  estimated  as  thirty-eight  shillings  ($9.50),  and  the  meat 
consumption  as  130  pounds  per  head  per  year,  whereas  the  peo- 
ple of  India,  with  their  weekly  income  of  two  shillings  or  less, 
live  on  rice  or  millet,  milk,  butter,  and  vegetables,  sparingly 
eaten.  In  consideration  of  these  facts,  it  has  been  maintained, 
although  the  contention  has  not  been  established,  that  the  man- 
ner of  living  must  be  a  factor  in  the  production  of  cancer. 

In  high-lying,  dry  districts,  whether  of  temperate  or  tropical 
countries,  cancer  is  said  to  be  relatively  less  frequent  than  in 
low-lying,  poorly  drained  regions,  although  exceptions  to  this 
statement  may  be  cited. 

In  Kashmir,  which  is  a  high-lying  valley,  surrounded  by 
mountains,  and  very  largely  inundated  all  the  time,  malignant 
and  other  tumors  are  not  rare  for  India.  From  1890  to  1899, 
inclusive,  2,000  natives  were  operated  upon  in  the  Kashmir 
hospitals  for  tumors,  most  of  which  were  malignant. 

Many  other  instances  are  cited  by  Haviland,^  who  maintains 
that  the  highest  cancer  mortality  is  found  in  low-lying  districts, 
which  are  watered  by  rivers  whose  waters  periodically  flood  the 
contiguous  territory.  He  cites,  as  proof  of  his  contention,  the 
Thames  and  its  tributaries,  which  traverse  "a  vast  cancer 
field."  The  only  localities  in  the  Thames  valley  where  the 
cancer  mortality  is  low  are  those  in  which  the  subsoil  consists 
of  substances  which  readily  absorb  the  water,  such  as  chalk  and 
oolite. 

The  Registrar-General's  reports  substantiate  this  view  with 
reference  to  some  sections  of  Great  Britain,  while  with  refer- 
ence to  others  this  does  not  seem  to  hold  true. 

Reviewing  the  influence  of  the  various  factors  concerned  in 
the  geographical  distribution  of  cancer,  Williams^  holds  that 
the  mortality  from  this  disease  is  lowest  where  the  struggle  for 
existence  is  hardest,  the  density  of  the  population  greatest,  the 

^  Haviland. — ' '  Geographical  Distribution  of  Disease  in  Great  Britain. '" ' 
1st  edit.,  1875;   2nd  edit.,  1892. 

Also :  ' '  The  Medical  Geography  of  Cancer  in  England  and  Wales, ' ' 
The  Practitioner,  1899,  LXII,  N.  S.  IX,  p.  400. 

'  Williams  W.  Eoger.— ' '  The  Natural  History  of  Cancer, ' '  1908. 


62  THE    CANCER    PROBLEM 

tuberculosis  mortality  highest,  the  birth-rate  highest,  the 
average  duration  of  life  shortest,  the  infantile  and  general  mor- 
tality highest,  and  where  sanitation  is  least  perfect.  In  other 
words,  according  to  his  findings,  the  cancer  mortality  is  lowest 
among  the  poor  of  the  industrial  classes  of  the  larger  cities, 
and  highest  among  agricultural  communities,  and  among  the 
prosperous  and  well-to-do  of  the  cities.  "High  feeding  and 
easy  living"  he  holds  to  be  the  most  potent  factors  in  the  causa- 
tion of  cancer.  In  other  words,  habits  of  life  are  given  an 
important  part  in  its  production. 

Exception  has  been  taken  to  the  numerical  methods  relied 
upon  by  Williams.  His  statements  are  not  in  keeping  with 
certain  recent  investigations.  The  Imperial  Cancer  Eesearch 
Fund  ^  has  called  attention  to  the  work  of  the  German  Imperial 
Colonial  Office,  as  reported  by  the  German  Cancer  Committee, 
from  Samoa,  German  East  Africa,  German  West  Africa, 
and  the  South  Sea  Islands.  Report  on  the  material  thus  for- 
warded states  that  carcinoma  is  by  no  means  rare,  as  is  gener- 
ally supposed,  in  these  countries.  The  relative  frequency,  it  is 
stated,  cannot  be  determined,  but  "it  is  certain  that  no  new 
growth  occurs  in  Germany  which  is  not  also  found  in  the  na- 
tives of  the  Tropics,  and  no  new  growth  occurs  in  the  Tropics 
which  is  not  found  in  Germany.  .  .  .  The  apparent  rarity  of 
malignant  new  growths  is  to  be  explained  by  the  fact  that  the 
natives  with  such  tumours  do  not  go  to  the  hospitals,  but  avoid 
them  and  die  unknown,  and  this  is  particularly  the  case  for 
internal  tumours." 

"This  agreement,"  comments  Bashford,  "in  the  results  ob- 
tained independently  through  the  investigations  of  the  German 
Imperial  Colonial  Office  and  the  Foreign,  India,  and  Colonial 
Offices  of  this  country,  should  go  far  to  dissipate  any  lingering 
belief  that  European  habits  of  life  are  primarily  responsible 
for  the  occurrence  of  cancer." 

Racial  Immunity. — It  has  been  claimed  by  some  investigators 
that  no  race  is  immune  from  cancer,  that  it  may  be  found  amona 
the  savages  of  the  jungles  of  Africa,  the  semi-civilized  natives^ 
of  the  Orient,  and  the  highly  civilized  inhabitants  of  occidental 
countries.  Others  have  read  into  the  statistical  findings  a  par- 
tial or  complete  immunity  among  members  of  certain  races  or 
nations,  the  reason  for  this  immunity  varying  with  the  par- 
ticular views  of  the  individual  student  of  the  problem. 

Some  are  inclined  to  believe  that  there  is  an  inherent  quality 
in  the  tissues  of  certain  races  which  renders  them  practically 
immune  from  cancer.  Others  hold  that  whatever  immunity  may 

1  Eleventh  Annual  Report. 


ETHNOLOGICAL    DISTRIBUTION  63 

seem  to  exist  arises  from  the  conditions  under  which  the  indi- 
viduals live,  and  that  changed  conditions  will  bring  about 
changes  in  the  degree  of  immunity.  Still  others  are  of  the 
opinion  that  no  race  is  immune,  and  that  closer  studies  of  the 
diseases  of  apparently  immune  races  will  reveal  the  number  of 
malignant  growths  increasingly  large  as  the  study  is  increas- 
ingly close. 

It  has  been  frequently  asserted,  and  great  importance  has 
been  attached  to  the  statement,  that  cancer  is  relatively  rare  in 
India,  Egypt,  and  other  countries,  and  in  aboriginal  races 
generally.  Yet,  as  we  have  seen,  closer  study  has  revealed 
cases  of  cancer  where  previously  the  disease  was  supposed  not 
to  exist,  where  there  is  little  reason  to  believe  that  it  could  be 
traced  to  any  possible  contamination  by  outside  races  or  na- 
tions, and  where  environmental  changes  were  hardly  suffi- 
ciently marked  to  account  for  its  sudden  occurrence.  Sporadic 
cases  have  been  reported  from  many  sections  where  the  aborig- 
inal natives  have  previously  been  supposed  to  be  exempt. 

One  of  the  examples  of  the  relative  immunity  from  cancer, 
so  often  cited,  is  furnished  by  Japan.  The  entire  country  has 
long  been  considered  remarkably  free  from  the  disease,  the 
peasantry  of  some  sections  being  cited  as  examples  of  complete 
immunity.  Yet,  within  the  last  few  years,  since  Japan  has 
made  such  rapid  strides  in  medicine,  as  in  other  fields  of  en- 
deavor, the  increasing  attention  devoted  to  the  study  of  cancer 
has  revealed  a  state  of  affairs  far  from  racial  immunity.  (See 
Section  III,  Statistical  Considerations.)  Japanese  statistics 
for  1899-1903  gave  the  average  death-rate  from  cancer  as  0.49, 
which  is  higher  than  that  of  such  countries  as  Servia,  Hungary, 
and  Spain.  As  the  methods  of  statistical  investigation  improve, 
the  disease  in  its  various  forms  will  doubtless  be  found  to  be 
much  more  frequent  in  Japan  than  is  now  suspected. 

It  is  fair  to  assume  that  the  same  would  apply  to  the  inhab- 
itants of  various  countries  supposed  to  be  relatively  immune, 
such,  for  example,  as  China,  Persia,  Arabia,  most  of  the  sec- 
tions of  Africa  inhabited  by  blacks,  the  various  islands  of  the 
Pacific,  the  Esquimos,  and  the  natives  of  other  cold  countries. 

From  the  foregoing  it  may  be  concluded  that  racial  immu- 
nity is  relative  and  not  absolute,  and  that  mankind,  wherever 
found  and  under  whatever  conditions  existing,  is  susceptible  to 
cancer  to  a  greater  or  lesser  degree. 

The  Influence  of  Environmental  Changes  in  the  Production  of 
Cancer. — Those  who  have  held  to  the  belief  that  aboriginal  peo- 
ples, uncontaminated  by  civilization  and  the  changed  condi- 
tions which  it  brings,  are  free  from  cancer,  have  been  accus- 


64  THE    CANCER    PROBLEM 

tomed  to  cite,  among  others,  the  inhabitants  of  New  Guinea 
and  various  other  islands  of  the  Pacific,  particularly  of  the 
South  Pacific.  It  is  interesting,  therefore,  to  review  the  inves- 
tigations of  the  Daniels  Ethnological  Expedition,  in  1904,  as 
reported  by  Seligmann,  in  the  Third  Scientific  Report  of  the 
Imperial  Cancer  Research  Fund. 

Studies  were  made,  during  eleven  months,  of  pathological 
conditions  among  the  inhabitants  of  New  Guinea  and  its  neigh- 
boring islands.  The  inhabitants  of  these  islands,  just  emerging 
from  the  Stone  Age,  and  so  little  contaminated  by  the  influence 
of  white  people  that  they  have  none  of  the  exanthemata  except, 
perhaps,  German  measles,  and  among  whom  venereal  diseases 
have  scarcely  made  any  inroads,  are  not,  as  it  was  formerly 
thought,  entirely  free  from  benign  and  malignant  new  growths, 
although  such  conditions  are  very  rare  among  them. 

Among  the  benign  new  growths  found  by  the  above-named 
investigators  may  be  mentioned  papillomata,  fibromata,  lipo- 
mata,  osteomata,  angiomata,  and  fibro-cheloid  formations. 
Among  the  malignant  tumors  found  were  encephaloid  cancer, 
sarcoma,  epithelioma,  and  rodent  ulcer  with  histological  charac- 
teristics of  malignancy. 

It  is  interesting  to  note,  in  connection  with  these  studies,  that 
the  natives  of  some  of  the  islands  were  found  to  be  peculiarly 
liable  to  chronic  ulcerative  and  irritative  processes,  and  that 
wounds,  which  are  very  common  among  them,  never  heal  except 
by  ' 'second  intention,"  every  native  past  middle  life  having  one 
or  more  scars  of  considerable  size.  These  possible  sources  of 
irritation,  therefore,  were  not  considered  as  being,  per  se,  suffi- 
cient to  produce  new  growths. 

It  was  also  noted  that  the  natives  are  free  from  gout,  arterio- 
sclerosis, and  other  conditions  due  to  faulty  metabolism,  and, 
as  we  have  already  seen,  that  syphilis  is  practically  absent.  For 
these  reasons  old  age  is  not  accompanied  by  the  retrogressive 
changes  which  are  supposed  very  largely  to  be  concerned  in  the 
production  of  malignant  disease.  The  absence  of  gout  and  the 
other  conditions  named,  among  certain  of  the  islanders,  may 
be  traced  to  the  fact  that  they  subsist  exclusively  upon  vege- 
table diet.  It  does  not  necessarily  follow,  •  however,  that  this 
mode  of  life,  as  some  maintain,  accounts  for  the  rarity  of  can- 
cer among  them,  for  the  reason  that  the  inhabitants  of  other 
neighboring  islands,  Australia,  for  example,  live  mostly  upon 
animal  food,  being  great  hunters  and  poor  gardeners,  and  yet 
both  benign  and  malignant  tumors  are  as  rare  among  them  as 
among  their  vegetarian  neighbors. 

From  these  studies  Seligmann  concludes  that,  in  the  rare 


ETHNOLOGICAL   DISTRIBUTION  65 

cases  of  malignant  disease  occurring  among  the  inhabitants  of 
the  various  islands  visited,  the  incidence  of  the  disease  seems 
to  be  associated  in  some  obscure  way  with  the  adoption  of  a 
mode  of  life  which  simulates,  to  a  certain  extent,  that  of  the 
white  man.  This  would  seem  to  substantiate  the  claim  often 
made  that  aboriginal  man  is  practically  immune,  and  that  the 
mode  of  living  is  an  important  factor  in  cancer  incidence,  en- 
vironmental changes  having  much  to  do  with  the  genesis  of  the 
disease.  Just  how  far  still  further  investigation  will  bear  out 
Seligmann's  findings  remains  to  be  seen.  In  the  meantime  it 
should  be  noted  that  the  length  of  Seligmann's  sojourn  in  Kew 
Guinea  may  not  have  sufficed  to  bring  him  into  very  intimate 
contact  with  the  inhabitants  of  an  island  which  is  notoriously 
difficult  of  exploration. 

It  has  been  maintained  by  Williams  that  the  chief  physical 
difference  between  savage  and  civilized  man  consists  in  the 
latter  being  better  nourished.  He  holds  that  cancer  is  of  most 
frequent  occurrence  among  prosperous,  highly  nourished  com- 
munities, and,  within  the  limits  of  such  communities,  to  be 
commonest  among  the  well-to-do.  His  theory  is  that  this  may 
be  explained  largely  upon  the  basis  of  environmental  changes, 
the  greatest  of  which  are  urbanization  and  the  enormous  in- 
crease of  riches  and  material  prosperity.  Sudden  and  marked 
environmental  changes,  as  from  the  pastoral  life  of  former 
times  to  the  pent-up,  crowded  life  which  the  majority  of  people 
now  lead  in  the  cities,  he  believes  to  be  responsible  for  the  in- 
crease in  cancer  in  all  occidental  countries.  The  rapid  en- 
croachment of  civilization  upon  savage  territory,  and  the  modi- 
fications, to  a  greater  or  less  extent,  of  the  methods  of  existence 
of  the  latter,  are  supposed  to  account,  at  least  in  part,  for  the 
increased  susceptibility  of  savage  races  coming  under  the  influ- 
ence of  civilization. 

It  has  been  shown  by  the  Registrar-General's  Reports  that 
the  lowest  cancer  mortality  is  found  where  conditions  of  life 
are  hardest.  Thus  the  rapid  increase,  within  the  last  century 
and  a  half,  of  wealth  and  general  material  prosperity  is  cited 
as  a  causative  factor  in  the  increase  of  cancer  in  Europe  and 
America. 

The  negro  is  often  cited  as  one  of  the  most  striking  illustra- 
tions of  the  influence  of  environmental  changes  upon  cancer 
genesis.  In  his  native  African  home,  under  the  surroundings 
which  for  centuries  remained  practically  the  same,  it  has  been 
thought,  inferentially  and  perhaps  incorrectly,  that  he  was 
immune  to  malignant  new  growths.  After  two  centuries  of  life 
under   new   conditions,    as   in   the    Southern    States,    the    ne- 


66  THE    CANCER    PROBLEM 

groes  no  longer  serve  as  examples  of  racial  immunity.  Whether 
or  not  this  is  due  to  a  real  increase  in  liability  or  to  the  results 
of  improved  observation  will  be  considered  later.  (See  Sec- 
tion III.) 

It  has  also  been  maintained  that  the  alleged  racial  immunity 
of  the  Jews  is  lost  when  they  live  under  conditions  which  seem 
to  favor  cancer  development  among  the  non-Jewish  people 
around  them,  although  it  is  still  maintained  by  some  that  they 
remain  less  liable  under  all  conditions  than  are  their  Gen- 
tile neighbors.  In  this  connection  the  reader  is  referred 
to  statistics  from  the  "Kosher  Wards"  of  certain  hospitals. 
(See  Section  III,  p.  96.) 

What  has  been  said  of  negroes  and  Jews  has  likewise  been 
stated  with  reference  to  the  North  American  Indians.^  They 
have  become  more  susceptible,  according  to  some  investigators, 
to  malignant  diseases  under  their  changed  environment. 

A  great  deal  has  been  written  to  prove  that  this  apparent 
increase  in  susceptibility  is  traceable  to  changes  in  diet,  and  a 
great  deal  more  has  been  written  to  disprove  any  such  claims. 
But  as  yet  we  have  insufficient  definite  knowledge  on  the  sub- 
ject, especially  before  the  changes  of  environment  took  place. 
A  more  extended  study  is  called  for  in  explanation  of  this 
alleged  loss  of  immunity  or  increase  of  susceptibility  under 
altered  environment. 

ILLUSTRATIONS  OF  THE  UNIVERSALITY  OF  CANCER 

INDIA 

India  has  attracted  considerable  attention  among  the  students 
of  cancer.  It  appears  an  interesting  field  for  investigation,  be- 
cause of  its  dense  population  and  the  poverty  and  abstemious 
methods  of  living  of  its  natives.  Particularly  does  it  interest 
those  who  hold  that  cancer  is  a  disease  of  overnutrition  or  other 
abnormal  environment. 

While  it  may  be  said  that  all  varieties  of  malignant  disease 
are  found  in  India,  certain  features  are  presented,  particularly 
with  reference  to  type  and  site-incidence  and  the  variations  of 
these  in  different  localities,  some  of  which  are  cited  below. 

David  W.  Sutherland,^  Professor  of  Medicine,  Lahore  Med- 
ical College,  made  a  study  of  the  cancer  cases  admitted  to  the 

1  Hoflfman,  Frederick  L. — ' '  The  Menace  of  Cancer, ' '  Trans.  Am.  Gyn. 
Soc,  1913. 

'Sutherland,  David  W. — "Statistics  of  Malignant  Disease  Admitted  to 
the  Mayo  Hospital,  Lahore,  Punjab,  India,  from  1892  to  1903  Inclusive" 
Archives  Middlesex  Hospital,  Third  Eeport  from  the  Cancer  Research 
Laboratories,  1904,  p.  84. 


HHB^"''^^^HMHi 

HIHHii 

Wm 

^■^jfMjW^WS^BBMM^BB^^B 

^S 

■ 

Plate  I. — Kangri  Basket. 


Plate  II. — Natives  of  Kashmir,  in  characteristic  attitudes,  using  Kangri 
baskets.  One,  standing,  is  wearing  a  basket  next  to  the  abdominal  skin. 
Two,  squatting,  have  baskets  between  thighs  and  knees.  These  natives 
thus  unwittingly  furnish  data  concerning  the  production  of  cancer  by 
chronic  irritation,  changing  entirely  the  relative  distribution  of  cancer  of 
the  skin  as  known  in  other  parts  of  the  world.  (Enlarged  from  the  Third 
Scientific  Report,  Imperial  Cancer  Research  Fund.) 


ETHNOLOGICAL    DISTRIBUTION  67 

Mayo  Hospital  in  Lahore,  which  draws  its  patients  from  all 
parts  of  the  Punjab  and,  to  some  extent,  from  other  adjacent 
states. 

From  these  records  he  found,  that  of  the  total  43,412  cases 
admitted  to  the  hospital  during  the  twelve  years  from  1892  to 
1903,  792  were  cases  of  malignant  disease.  Of  this  number 
the  classification,  as  given  in  the  registers,  was  as  follows :  Car- 
cinoma, 400;  Sarcoma,  334;  "Abdominal  Growths,"  35,  and 
"Malignant  Growths,"  23. 

From  the  statistics  collected  Sutherland  concludes  that  they 
bear  out  the  general  principle  that  cancer  tends  to  occur  at  the 
sites  of  chronic  irritation  where  there  is  constant  need  for  cell 
repair.  Fifty-eight  cases  of  epithelioma  and  thirty-six  of  ro- 
dent ulcer  occurred  in  the  skin,  which  in  India  is  so  universally 
the  seat  of  injury  because  of  the  scanty  clothing  worn  by  the 
natives,  ^and  because  of  certain  habits  of  life  among  them. 

The  Mohammedans,  for  example,  shave  the  head  as  a  whole, 
the  Hindus  in  part,  and  the  irritation  from  blunt  razors  is 
supposedly  the  cause  of  the  large  number  of  scalp  cancers. 

"Kangri  Cancer"  ^-^ — epithelioma  of  the  skin  of  the  front 
abdominal  wall — is  a  common  form  among  the  natives  of  Kash- 
mir, a  province  adjoining  the  Punjab.  This  is  attributable  to 
the  Kangri  burn,  a  long-continued  irritation  produced  by  the 
Kangri.  The  Kangri  is  a  small  earthenware  vessel  surrounded 
by  basket  work,  used  to  contain  a  charcoal  fire,  and  worn  by 
the  natives  suspended  from  the  waist,  under  the  flowing  robes 
and  next  to  the  skin,  for  the  purpose  of  protecting  them  against 
the  cold  (Plates  I  and  II).  The  prolonged  irritation  pro- 
duced by  this  means  very  often  eventuates  in  epithelioma  of 
the  skin,  with  metastasis  in  neighboring  lymph  glands. 

Cancer  of  the  penis  is  practically  unknown  among  the  Mo- 
hammedan population  of  India,  presumably  in  consequence  of 
the  universal  practice  among  them  of  circumcision,  and  the 
removal  thereby  of  the  element  of  chronic  irritation  produced 
by  the  accumulation  of  dirt  and  secretion  under  the  prepuce, 
where  circumcision  is  not  practised,  as  among  the  Hindu  paj-t 
of  the  population. 

Cancer  of  the  lip,  tongue,  cheek,  and  buccal  mucous  mem- 
brane is  of  relatively  frequent  occurrence  in  both  sexes  in 
India,  in  consequence  of  the  chronic  irritation  produced  by 

1  Neve,  E.  F.— "Decade  of  Tumour  Surgery  in  Kashmir  Mission  Hos- 
pital," Indian  Med.  Gazette,  May,  1902,  p.  164. 

sBashford,  E.  F.— "The  Ethnological  Distribution  of  Cancer,"  Third 
Scientific  Report  on  the  Investigations  of  the  Imperial  Cancer  Research 
Fund,  1908,  p.  1. 


68  THE    CANCER    PROBLEM 

The  chewing  or  hokliiiii-  in  the  mouth  of  a  mixture  of  betel 
leaves,  areea  nut,  tobacco,  and  slaked  lime.  This  is  supposedly 
analogous  to  the  "clay  pipe'"  cancer  of  other  countries. 

The  tendency  of  cancer  to  eifect  the  lower  parts  of  the  intes- 
tinal tract  is  supposedly  traceable  to  the  fact  that  the  vege- 
tarian diet  of  the  natives  calls  for  intestinal  rather  than  gastric 
digestion.. 

GILBERT    ISLANDS  1 
(British  Archipelago  in  Oceaixica) 

Alexander  Robertson,-  M.B.,  CM.,  Medical  Officer  Gilbert 
and  Ellice  Islands  Protectorate,  reports  four  cases  of  cancer  in 
natives,  as  follows :  scirrhus  cancer  of  right  breast  in  a  female, 
oi  ;  cancer  of  uterus,  28  ;  cancer  of  lower  lip,  cheek,  and  tongue, 
male,  55 ;  carcinoma  of  uterus,  40. 

These  cases  were  from  Tarawa.  He  was  unable  to  say 
whether  malignant  disease  was  prevalent  in  other  islands  of 
the  group.  He  mentions  two  cases  which  had  been  reported  to 
him.  The  first  was  epithelioma  of  the  lip  in  a  native  of  Ocean 
Islands,  and  the  other  carcinoma  of  the  breast  in  a  native  of 
Union  Islands, 

ICELAND 

Lazarus-Barlow  ^  made  a  study  of  the  occurrence  of  cancer 
in  Iceland,  as  compared  with  its  occurrence  in  Lahore,  as  re- 
ported by  Professor  Sutherland  (loc.  cit.). 

The  information  obtained  by  Lazarus-Barlow  was  contained 
in  reports  furnished  him  by  the  Royal  Board  of  Health  in 
Copenhagen,  and  by  Dr.  Jonasson,  First  Medical  Officer  in 
Reykiavik. 

From  these  reports  it  appears  that  Iceland  has  not  been 
exempt  from  cancer,  although  the  disease  has  always  been,  and 
still  is,  of  uncommon  occurrence  in  that  country.  It  has  been 
fairly  evenly  distributed  over  the  country,  and  has  been  marked 
by  the  usual  symptoms  and  sequences. 

It  seems,  however,  from  the  annual  reports  furnished  to  the 
Royal  Board  of  Health  at  Copenhagen  from  about  18G6  on- 

1  British  Archipelago  in  Oceaniea — 16  small  islands  covering  a  total  area 
of  about  166  square  miles.  About  36,000  colored  inhabitants,  mostly 
uncivilized,  but  including  a  number  of  converts  to  Christianity.  The 
group  was  discovered  in  1765,  and  came  into  possession  of  Great  Britain 
in  1892. 

-  Robertson,  Alexander. — * '  Cancer  in  the  Gilbert  Islands, ' '  Journal  of 
Tropical  Medicine,  November  1,  1905,  p.  317. 

*  Lazarus-Barlow,  W.  S. — ' '  A  Note  on  Cancer  in  Iceland, ' '  Archives 
of  the  Middlesex  Hospital,  Fourth  Eeport  from  the  Cancer  Research  Lab- 
oratories,  1905,  p.  273. 


ETHNOLOGICAL   DISTRIBUTION  69 

ward,  that  cancer  was  extremely  rare  in  Iceland  previous  to 
the  year  1896.  About  this  time  (1896)  "unusually  many"- 
cases  were  reported.  From  1890  to  1900,  115  cases  were  re- 
ported. Judging  from  the  site  incidence  in  these  cases,  car- 
cinoma, rather  than  sarcoma,  was  the  type  of  disease  mani- 
fested, although  the  diagnoses  were  clinical,  no  microscopic  or 
pod-mortem  examinations  having  been  made.  The  population 
of  Iceland  during  the  decade  mentioned  ranged  from  69,977 
in  1890  to  76,308  in  1900.  The  number  of  cases  of  cancer 
reported  during  these  years  ranged  from  2  in  1890  to  22  in 
1900. 

More  than  half  the  number  of  cases  recorded  were  said  to 
affect  the  stomach,  only  20  out  of  the  115  cases  involving  other 
parts  of  the  alimentary  tract.  The  lip  was  involved  in  13 
cases,  the  tongue  in  4,  the  face  in  1,  the  esophagus  in  5,  the 
stomach  in  58,  the  liver  and  stomach  in  4,  the  intestines  in  4, 
the  rectum  in  2,  the  uterus  in  5,  and  the  breast  in  15  cases  of 
the  total  115. 

The  complete  absence  of  cancer  of  the  penis  was  noted  as 
compared  with  its  frequent  occurrence  among  Hindus. 

Compared  with  the  records  of  the  Middlesex  Hospital,  Laz- 
arus-Barlow noted  the  relative  frequency  of  cancer  of  the 
stomach  and  parts  of  the  alimentary  tract  in  Iceland,  and  the 
tendency  of  the  disease  to  affect  the  lower  parts  of  the  ali- 
mentary tract  in  India. 

SUMMARY 

The  influence  upon  cancer  incidence  of  climate,  soil,  diet, 
and  habits  of  life  has  not  been  proved.  In  other  words,  it  has 
not  been  established  that  any  of  these  factors  are  potent  to 
absolutely  prevent  the  occurrence  of  cancer.  Extended  study 
of  the  geographical  and  ethnological  distribution  of  the  disease 
tends  more  and  more  to  show  that  no  country,  no  district,  no 
race,  no  nation  may  be  considered  as  possessing  immunity. 
The  supposed  freedom  of  savage  and  semi-civilized  races  is 
accounted  for,  at  any  rate  in  part,  by  the  relatively  small  num- 
ber of  these  individuals  who  have  been  examined,  by  age  inci- 
dence, and  by  other  factors  not  concerned  with  geographical 
and  ethnological  questions.  There  are  no  data  which  permit 
of  an  accurate  comparison  of  the  frequency  of  cancer  in  differ- 
ent parts  of  the  world  inhabited  by  the  same  race,  for  example, 
the  Teutonic  and  Latin  stocks  in  America  and  Europe,  and 
the  negro  in  Africa  and  in  the  United  States.  Similarly  no 
comparison  can  be  made  between  different  races  of  mankind. 


SECTION    III 

STATISTICAL    CONSIDERATIONS 

SIGNIFICANCE    AND    VALUE    OF    STATISTICAL    STUDIES 

Opia'ion  concerning  the  importance  to  be  attached  to  the 
application  of  statistical  methods  to  medical  problems  has 
varied  from  time  to  time.  At  one  time  the  value  of  statistics 
was  grossly  exaggerated.  It  was  then  supposed  that  by  statis- 
tical methods  alone  it  was  possible  to  define  the  etiological 
relationships  existing  between  phenomena  occurring  together 
or  following  upon  one  another.  At  another  time  statistics  were 
greatly  undervalued,  or  discarded  altogether  as  yielding  only 
ambiguous  results.  "You  may  draw  any  conclusion  you  like 
from  statistics"  was  often  the  comment  with  which  they  were 
dismissed  from  serious  consideration. 

To-day,  however,  there  prevails  a  more  just  appreciation  of 
the  proper  value  and  legitimate  application  of  statistics.  Mem- 
bers of  the  medical  profession  are  learning  to  differentiate 
between  mere  juggling  with  figures  and  really  valuable  statis- 
tical work. 

It  is  only  by  collecting  accurate  statistics  of  illness  or  of 
death  that  the  relative  healthfulness  of  a  country,  a  town,  or  a 
trade  may  be  determined.  And  it  is  only  by  separating  the 
different  causes  of  death  from  each  other,  and  stating  them  in 
percentages  of  the  population,  in  what  are  known  as  "vital 
statistics,"  that  the  value  of  improved  sanitation  and  other 
better  conditions  of  living  has  been  established,  and  that  such 
practices  have  been  generally  promoted. 

Statistical  studies  have  contributed  very  largely  to  the  ad- 
vancement of  knowledge  concerning  cancer  in  the  past,  and 
continue  to  do  so  to-day.  All  such  matters  as  the  zoological, 
ethnological,  and  geographical  distribution  of  cancer  are  essen- 
tially statistical.  The  distribution  of  cancer  in  the  two  sexes ; 
its  relative  frequency  in  different  parts  of  the  body;  the  ages 
most  liable  to  it;  the  effect  of  climatic  conditions,  of  soil,  diet, 

70 


STATISTICAL    CONSIDERATIONS  71 

jilcoliol,  tobacco,  and  occupation;  the  influence  of  child-bear- 
ing, and  the  effects  on  women  of  their  inability  or  refusal  to 
suckle  their  offspring;  the  results  obtained  by  surgical  and 
other  treatment — all  are  capable  of  statistical  study  from  a 
theoretical  point  of  view.  From  the  practical  point  of  view, 
however,  many  difficulties  are  encountered  in  such  studies,  in 
some  instances  insurmountable,  and  in  others  not  yet  sur- 
mounted. 

DIFFICULTIES    ENCOUNTERED    IN    THE    COLLECTION    OF 
STATISTICS 

For  acute  diseases  the  collection  of  data  and  the  compilation 
of  valuable  statistics  are  easy,  especially  if  the  disease  attacks 
almost  solely  one  period  of  life,  for  example,  childhood ;  and  if 
the  two  sexes  do  not  require  to  be  separately  treated.  With  the 
increase  in  the  duration  of  illness  before  death,  the  difficulty 
increases,  especially  if  the  liability  be  spread  over  many  de- 
cennia  of  life,  and  if  the  two  sexes  have  a  different  liability. 

All  of  these  difficulties  are  met  in  their  highest  degree  in 
the  case  of  cancer.  In  many  countries  and  towns,  where  quite 
useful  statistics  are  available  for  infectious  diseases,  such  are 
still  entirely  unreliable  or  absolutely  lacking  for  cancer. 

The  literature  of  the  statistics  of  cancer  is  enormous  but  of 
very  unequal  value,  and  nowhere  else  does  the  bewildering 
conflict  of  fact  and  fiction  appear  to  stand  forth  more  promi- 
nently. Yet  this  bewilderment  is  chiefly  due  to  faulty  statis- 
tical methods,  to  tabulations  of  figures  utterly  unworthy  of 
being  styled  statistics  at  all,  and  even  to  reliance  on  mere  hear- 
say statements  that  cancer  either  occurs  or  does  not  occur  under 
certain  given  circumstances.  If  it  were  frankly  admitted  that 
no  reliable  information  is  obtainable,  and  that,  under  many 
circumstances,  the  data  on  which  accurate  statistics  could  be 
bpsed  are  not,  and  are  never  likely  to  be,  available,  there  would 
be  no  occasion  for  much  futile  discussion. 

Thus,  wide  currency  has  been  obtained  for  the  view  that  can- 
cer is  rare  in  Japan  because  of  the  native  habit  of  frequent 
bathing,  or  because  the  Japanese  are  largely  rice-eaters ;  that  it 
is  rare  in  Hindustan  because  of  the  vegetarian  diet  of  many 
castes ;  and  that  it  is  quite  unknown  in  uncivilized  races  remote 
from  civilization. 

The  alleged  rarity  of  the  disease  under  any  one  or  all  of 
the  above  circumstances  has  been  urged  with  equal  vehemence, 
according  to  the  widely  divergent  views  held  by  extremists  of 
one  or  another  school  of  partisans,  as  "proof"  that  cancer  has 


72  THE    CANCER    PROBLEM 

a  parasitic  or  dietetic  etiology.  The  goodly  output  of  litera- 
ture which  has  appeared  in  book  and  magazine  form  has  ob- 
tained prominence  in  the  newspapers  for  these  extremes  of 
opinion,  and  statements  alleging  the  large  increase  of  cancer 
among  civilized  peoples,  and  the  widely  divergent  possibilities 
suggested  for  its  development,  have  contributed  not  a  little  to 
the  public  alarm  and  dread  of  the  disease. 

UNIVERSALITY    OF    CANCER    AS    SHOWN    BY    STATISTICAL 

STUDIES 

The  investigations  of  the  Imperial  Cancer  Research  Fund 
have  shown  that  the  disease  occurs  among  all  races  of  mankind 
— among  those  not  living  in  close  contact  with  civilization  as 
well  as  among  those  that  are.  Exemption  is  not  conferred  by 
any  of  the  many  diverse  conditions  of  life  found  among  widely 
separated  and  primitive  aboriginal  races.  Contrary  to  what 
was  formerly  believed,  the  disease  is  frequent  in  Japan,  India, 
Eg}'pt,  and  China.  Thus  the  ground  has  been  completely  cut 
from  under  the  feet  of  the  honest  but  visionary  propagandists 
who  have  based  their  arguments  upon  the  unsupported  asser- 
tions that  cancer  did  not  occur  in  this  or  that  portion  of  the 
globe. 

POSSIBLE    ERRORS    IN    THE    COMPILATION    OF    STATISTICS 

As  regards  the  relative  frequency  of  cancer  in  different  races 
and  in  different  parts  of  the  world,  there  are  absolutely  no  re- 
liable data.  It  cannot  be  denied  that  the  disease  is  much  more 
frequently  recorded  in  some  countries  than  in  others,  but  there 
our  exact  information  ceases.  It  cannot  now  be  stated  whether 
the  difference  is  merely  a  question  of  recording  the  disease,  or 
whether  the  relative  proportions  of  the  two  sexes  and  the  re- 
spective ages  attained  by  them  do  not  largely  contribute,  be- 
cause, except  in  a  few  European  countries,  these  essential  data 
are  not  forthcoming. 

In  different  countries  there  are  wide  variations  in  the  rela- 
tive numbers  of  males  and  females,  and  also  in  the  relative 
numbers  of  males  and  females  living  at  each  age-period.  These 
variations  in  what  is  technically  known  as  the  age  and  sex  con- 
stitutions of  the  several  populations  introduce  fallacies  when 
comparison  is  made  by  crude  death  rates,  in  which  the  deaths 
are  simply  stated  as  per  1,000  persons  living  at  all  ages,  both 
sexes  being  thrown  together.  It  is  therefore  necessary  to  cal- 
culate corrected  death  rates,  in  which  allowance  is  made  for 
these  differences  in  age  and  sex  constitution. 


STATISTICAL    CONSIDERATIONS 


73 


The  Registrar-General  of  England  has  done  this  for  all 
countries  able  to  supply  the  necessary  primary  data.  Unfor- 
tunately it  must  be  admitted  that  America  has  been  unable  to 
supply  satisfactory  details,  for  which  reason  American  statis- 
tics are  omitted  from  the  following  table.  The  age  and  sex 
constitution  of  the  populations  of  England  and  Wales  at  the 
census  of  1901,  has  been  adopted  as  the  standard  for  compari- 
son, and  from  it  the  following  table  is  obtained : 


Cancer. — Death-rates  per 

1,000  Persons  Living,  1881-1910 

Countries 

Crude  Rates 

Corrected  Rates 

of  crude  rates 
in  1901-5.) 

1881- 
1885 

1886- 
1890 

1891- 
1895 

1896- 
1900 

1901- 
1905 

1906- 
1910 

1906- 
1910 

1909 

1910 

Switzerland .... 

1.03 
0.60 
0.55 
0.54 
0.44 
0.38 
0.30 
0.34 

0.36 

1.14 
0.70 
0.63 
0.62 
0.50 
0.43 
0.42 
0.41 

0.42 

1.22 
0.81 
0.71 
0.69 
0.59 
0.49 
0.52 
0.50 

0.49 

1.27 
0.92 
0.80 
0.77 
0.69 
0.58 
0.59 
0.57 

0.57 

1.28 
0.97 
0.87 
0.85 
0.74 
0.69 
0.67 
0.65 

0.63 
to.  58 
0.55 
0.44 
0.39 
0.10 

1.07 
0.90 
0.96 
1.00 
0.73 
0.65 
0.82 
0.74 

0.85 
0.54 
0.53 
0.44 
0.44 

New  Netherlands .... 
England  and  Wales . . 
Scotland 

1.03 

0.94 

0.90 
0.94 

0.93 
0.97 

Austria 

0.78 
0.79 
0.72 
0.74 

0.70 

0.73 
0.64 
0.81 
0.73 

0.83 

0.73 

Ireland 

0.68 

New  Zealand 

Prussia 

0.84 
0.77 

Australian  Common- 
wealth   

0.87 

Belgium 

Italy 

*0.43 

0.44 

0.51 

Spain 

0.50 
0.44 

0.44 
0.43 

0.45 

Hungary 

*0.30 
0.08 

0.45 

Servia 

*0.60 

•4  years. 


1 3  years. 


Even  with  these  corrections,  as  shown  in  th^  table,  there  are 
great  variations  in  the  recorded  frequency  of  cancer  for  differ- 
ent European  countries.  Some  authors  lay  weight  on  these 
differences  and  regard  them  as  real;  others  hold  that  the  dif- 
ferences are  in  the  main  merely  an  expression  of  the  reliability 
of  the  statistics,  and  that  as  the  amount  of  cancer  diminishes 
so  does  the  inexactness  of  the  statistics  increase.  For  some 
European  countries  statistics  are  available  only  for  the  towns. 


FALLACIES    IN    AMERICAN    METHODS    OF    COMPILING    STATISTICS 

In  America  the  state  of  affairs  is  even  worse.  The  inter- 
national scheme  for  the  tabulation  of  deaths  is  employed  in 
practically  all  states.  American  statisticians  have  ably  con- 
tributed to  the  development  of  statistical  science  in  general, 
particularly  in  developing  the  plan  of  assorting  data  mechan- 
ically by  the  card  system,  but  they  have  not  been  provided  with 


74,  THE    CANCER    PROBLEM 

cancer  data  upon  which  to  work.  Hence  there  are  no  reliable 
statistics  concerning  either  the  relative  frequency  of  cancer  in 
the  past  as  compared  with  the  present,  or  its  relative  frequency 
in  different  states,  in  different  to^vns,  or  in  town  as  compared 
with  country  districts. 

Instead  of  the  essential  data  of  population — the  relative  pro- 
portions of  the  two  sexes,  and  the  numbers  in  the  respective 
age  groups  of  each  sex  being  set  forth  and  brought  into  relation 
with  the  deaths  from  cancer — we  find  the  deaths  classified  ac- 
cording to  months,  or  per  100,000  or  10,000  of  population,  or 
even  per  1,000  deaths  from  all  causes,  as  in  the  map  compiled 
for  the  United  States  by  McConnell  and  reproduced  on  page 
76.  Inasmuch  as  the  season  of  the  year  has  no  influence 
on  the  death-rate  from  cancer,  as  it  has  on  infective  diseases, 
the  classification  of  cancer  deaths  according  to  months  is  an 
error.  The  consideration  of  the  two  sexes  together  is  likewise 
a  great  statistical  fallacy.  The  methods  employed  by  different 
states  vary  in  other  ways,  but  almost  without  exception  in  a 
direction  contrary  to  that  which  would  lead  to  improvement. 

This  deplorable  state  of  affairs  is  often  due  to  the  system 
under  which  those  responsible  for  the  registration  of  deaths 
and  the  compilation  of  statistics  are  appointed.  The  result  is 
seen  in  the  production  of  mere  worthless  tabulations  of  figures, 
which  cannot  by  any  possibility  be  given  the  value  of  statistics. 
American  methods  and  their  results  justified  Bashford  in  stat- 
ing, in  New  York  in  1912,^  that  he  knew  more  about  the  occur- 
rence of  cancer  in  the  different  native  races  of  Ceylon  than  his 
audience  did  about  cancer  among  the  different  races  in  their 
own  city.     His  criticism  has  not  been  answered. 

American  statistics  also  suffer,  as  emphasized  by  Oertel,^ 
from  the  rarity  with  which  autopsies  are  performed.  Oertel 
publishes  figures  showing  how  large  a  proportion  of  autopsies 
are  performed  in  Europe,  and  other  authors  have  demonstrated 
how  high  a  proportion  (20-40  per  cent.)  of  deaths  from  cancer, 
especially  internal  cancer,  are  recognized,  even  in  hospitals, 
only  after  an  operation  or  autopsy  is  made.  The  well-known 
and  deplorable  difficulty  of  obtaining  autopsies  in  America  has 
its  bearing  upon  many  phases  of  medical  progress,  not  the  least 
of  which  is  concerned  with  the  compilation  of  reliable  statistics 
with  reference  to  cancer. 

The   unfortunate   condition   of   the    vital    statistics    of   the 

1  "  A   Eeview   of    Recent   Cancer    Research. ' ' — The   Middleton- Goldsmith 

Lecture,  New  York  Pathological  Society,  October,  1912. 

'Oertel,   H. — "The   Inaccuracy   of   American   Mortality  Statistics    (with 
comment),"  American  Underivriter,  Vol.  XXXIX,  May,   1913. 


STATISTICAL    CONSIDERATIONS 


75 


United  States  is  described  in  the  "Physicians'  Pocket  Refer- 
ence to  the  International  List  of  Causes  of  Death"  (2nd  Edi- 
tion, 1913),  which  is  issued  to  every  physician  in  the  United 
States  by  the  Bureau  of  the  Census,  Washington,  D.  C.  The 
first  edition  of  this  valuable  booklet  was  sent  out  in  January, 
1911.  The  Director  of  the  Census,  William  Harries,  states  in 
the  preface  to  the  second  edition,  that  "it  has  been  of  great 
service  in  improving  the  quality  of  the  returns  of  causes  of 
death,  and  has  further  aided  in  showing  the  importance  of 
vital  statistics,  of  adequate  legislation  for  this  purpose,  and  of 
the  thorough  enforcement  of  existing  laws."  The  second  edi- 
tion gives  the  map  here  reproduced  (Fig.  1),  showing  the 
growth  of  the  registration  area  by  the  addition  of  many  fresh 
states  in  recent  years,  and  enforces  the  need  for  carrying  out 
the  registration  of  births  and  deaths. 

Although  the  booklet  is  issued  to  every  physician  in  the 
United  States,  it  is  pointed  out  how  grievously  the  law  is  ig- 
nored. Public  opinion  in  the  country  requires  to  be  aroused 
to  the  practical  value  of  universal  birth  and  death  registration, 


Fig.  1. — Map  showing  true  state  of  American  Vital  Statistics  in  1900. 


if  anything  more  than  the  rough  computations  of  the  deaths 
from  cancer  and  other  diseases  is  to  be  made  available  for  the 
guidance  of  investigation. 

The  map  given  by  McConnell  ^    is  also  reproduced    (Fig. 

^McConnell,  Guthrie. — "Die  Krebskrankheit  in  den  Vereinigten  Staaten 
von  Nordamerika, "  Zeitschr.  f.  Krebsforschung,  1908,  Bd.  VII. 


76 


THE    CANCER    PROBLEM 


2)  for  comparison  with  the  map  given  by  the  Bureau  of  the 
Census  showing  the  growth  of  the  registration  area  for  the 
United  States.  Comparison  of  the  two  maps  shows  that  in 
1900  only  eleven  of  the  many  states  indicated  as  giving  cancer 
data  in  McConnell's  map  had  joined  the  registration  area.     A 


Fig.  2. — Map  of  McConnell  reduced  to  same  scale  as  above,  giving  by  degree 
of  black  "the  proportion  of  deaths  from  cancer  per  1,000  deaths  from  aU 
causes,  in  1900."  A  comparison  of  the  two  maps  shows  that  the  facta 
in  the  first  map  prove  that  the  second  map  has  no  value  whatsoever. 

moment's  reflection  shows  how  futile  it  is  to  attempt  to  estab- 
lish the  relative  frequency  of  cancer  in  the  several  states  in  the 
present  condition  of  American  vital  statistics. 


IMPORTANCE    OF    AUTOPSIES    IN    THE    COMPILATION    OF    CANCER 

STATISTICS 

Bashford  and  Murray  ^  point  out  the  frequency  with  which 
malignant  new  growths  present  themselves  at  post-mortem  ex- 
aminations. The  following  table,  giving  the  total  number  of 
autopsies  and  the  total  number  of  cases  of  malignant  new 
gro\\i;hs  for  a  number  of  years  at  a  single  hospital,  namely 
Guy's  Hospital,  London,  shows  that  on  the  average  one  case 
of  malignant  disease  has  occurred  in  every  eight  autopsies.  It 
may  be  added  that,  as  long  ago  as  1888,  in  82  per  cent,  of  the 
cases  of  malignant  new  growths  thus  presenting  themselves,  a 
microscopical  examination  is  recorded. 

1 ' '  The  Statistical  Study  of  Cancer, ' '  Second  Scientific  Report  of  the 
Imperial  Cancer  Research  Fund,  London,  1905,  p.  41. 


479 

64 

457 

76 

462 

71 

449 

58 

483 

52 

536 

63 

516 

63 

495 

61 

507 

46 

478 

62 

494 

61 

494 

49 

474 

41 

467 

49 

6,791 

816 

One  case  in  eight. 

STATISTICAL    CONSIDERATIONS  77 

Year.  Autopsies.       Malignant. 

1901 

1900 

1899 

1898 

1897 

1896 

1895 

1894 

1893 

1892 

1891 

1890 

1889 

1888 

Total  for  14  years 


Keliable  statistics  of  cancer  require  the  collection  of  a  large 
number  of  data  having  reference  to  the  population  as  a  whole, 
the  relative  numbers  of  males  and  females  and  the  numbers  in 
each  age  group  for  each  sex.  Accurate  certification  of  the  cause 
of  death  in  every  case  can  result  only  from  uniform  post-mortem 
examination,  which  is  impracticable;  but  by  insisting  that  the 
certification  of  cause  of  death  must  be  made  by  a  medical  man, 
or  that  the  body  after  death  shall  be  examined  by  one,  mortality 
statistics  have  been  freed  from  many  sources  of  fallacy. 


FACTORS    TO    BE    CONSIDERED   IN   CALCULATING    CANCER 
DEATH-RATE 

Age  aiid  Site  Incidence. — The  cancer  death-rate  must  be  con- 
sidered according  to  age  and  stated  in  terms  of  the  prop6rtion 
of  each  sex  living  at  each  corresponding  quinquennial  or  decen- 
nial age  group.  It  is  thus  found,  if  all  cases  of  cancer  are  taken 
together,  that  below  35  cancer  is  rare,  but  that  it  increases  in 
frequency  from  that  age  to  the  end  of  life.  There  was  long  a 
fundamental  difficulty  in  further  analyzing  this  phenomenon 
because  the  official  figures  of  different  countries  neither  differ- 
entiated sarcoma  from  carcinoma,  nor  stated  the  different  sites 
of  the  disease.  For  England  and  Wales  this  difficulty  has  been 
overcome,  and  a  most  interesting  analysis  made.  The  English 
Statistical  Office  responded  to  the  emphasis  laid  upon  the  im- 
portance of  incidence  on  different  sites  in  the  body,  as  shown 
by  the  comparison  instituted  by  Bashf  ord  and  Murray  ^  be- 
tween the  age-incidence  of  cancer  in  short-  and  long-lived  ani- 

1  Ibid. 


78 


THE    CANCER    PROBLEM 


mals,  and  bv  the  fact  that  several  organs  of  the  hnraan  body 
have  varied  importance  at  different  ages.  The  rehition  of  mor- 
tality to  age  varies  considerably  for  cancer  of  different  organs, 
but  little  for  the  same  organ  in  the  two  sexes. 

If  the  nterus  and  breast  be  considered  apart,  the  accom- 
panying table,  taken  from  the  Report  of  the  Kegistrar-General 
of  England  for  1909,  shows  that  there  is  some  one  period  of 
life,  generally  the  same  for  both  sexes,  at  which  cancer  of  any 
particular  organ  is  especially  characteristic.  Cancer  of  the 
face  and  lip  have  the  mortality  concentrated  upon  the  extreme 
end  of  life,  whereas  cancer  of  the  tongue  has  its  maximum 
comparatively  early. 

England  and  Wales. — Cancer:  Parts  of  Body,  1901-9. — Percentage  of  Deaths  at 
Each  Age-group  to  Total  Deaths  from  Cancer  in  the  Same  Sex  and  Age- 
Group. 


0-35 

35- 

45- 

55- 

65- 

75- 

85  and 

All 

agea 

Males 
Face 

0.9 
0.1 
8.7 
6.3 
7.1 
0.1 
0.7 
7.0 
1.2 
0.8 
0.6 
2.3 
64.2 

0.6 
0.0 
6.0 
4.9 
5.4 

22.8 
9.2 
1.9 
5.1 
0.3 
0.9 
0.4 
1.5 

41.0 

1.4 
0.7 

20.9 
8.0 
8.6 
0.1 
5.0 

10.6 
2.1 
5.5 
1.5 
3.0 

32.6 

0.3 

0.0 

8.9 

4.5 

4.6 

36.0 

19.6 

1.8 

6.9 

0.5 

0.5 

0.2 

0.6 

15.6 

1.2 
0.7 

21.5 
7.2 
9.0 
0.2 
8.0 

11.1 
2.4 
7.7 
2.0 
3.5 

25.5 

0.4 
0.0 

11.6 
5.8 
4.9 

29.6 

19.4 
1.4 

10.5 
0.6 
0.4 
0.1 
0.6 

14.7 

1.2 
1.1 

22.4 
7.6 

10.4 
0.2 
7.9 

13.3 
2.9 
6.2 
1.8 
2.9 

22.1 

0.5 
0.0 

15.4 
7.8 
6.1 

21.5 

15.8 
1.3 

15.2 
0.9 
0.4 
0.2 
0.7 

14.2 

1.9 
1.8 

23.1 
8.9 

11.1 
0.2 
6.1 

13.7 
4.0 
4.7 
1.8 
2.6 

20.1 

1.0 
0.1 

18.0 
9.6 
6.8 

15.1 

14.5 
1.6 

16.8 
1.2 
0.5 
0.3 
0.7 

13.8 

4.3 
4.0 

20.2 
9.0 

11.4 
0.3 
4.7 

13.3 
4.0 
4.1 
1.7 
2.8 

20.2 

2.6 

0.3 

16.5 

10.0 

7.2 

11.4 

17.7 

1.7 

15.7 

1.5 

0.7 

0.2 

0.9 

13.6 

10.8 
9.6 

12.8 
6.6 
9.9 
0.5 
3.5 

12.1 
4.5 
3.2 
2,1 
2.0 

22.4 

6.0 
0.6 

11.2 
8.6 
6.0 
9.5 

27.3 
1.3 

11.2 
1.5 
0.6 
0.3 
0,9 

15.0 

1.9 

Lip                      

1.6 

Stomacli ...        

21.4 

Intestines 

8.0 

Rectum 

10,2 

Breast 

0,2 

Qilsophagus 

6,5 

Liver  and  Gall  Bladder. . .  . 

Bladder  and  Urethra 

Tongue 

12,5 
3,1 
5,5 

Mouth 

1.8 

Jaw . .             

2.9 

Other  Organs 

24.4 

Females 
Face 

0.9 

Lip    

0,1 

Stomach 

14,2 

Intestines 

7,6 

Rectum 

6.0 

Uterus 

22.0 

Breast 

16.8 

(Esophagus 

1  5 

Liver  and  Gall  Bladder .... 

Bladder  and  Urethra 

Tongue 

13.3 
0.9 
0.5 

Mouth 

0  2 

Jaw  .      .        

0.7 

Other  Organs 

15.3 

Sex. — The  mortality  figures  for  the  principal  cancers  of  the 
alimentary  tract,  stomach,  liver,  gall-bladder,  and  rectum,  are 


STATISTICAL    CONSIDERATIONS  79 

seen  from  the  table  to  be  very  similar  in  tlie  two  sexes ;  but  in 
the  male  there  is  more  cancer  of  the  stomach  and  rectum,  and 
in  the  female  more  of  the  liver  and  intestines.  The  liver  occu- 
pies an  exceptional  position  in  both  sexes,  because  most  of  the 
cancers  occurring  in  that  organ  are  secondary  to  cancer  else- 
v^here  in  the  alimentary  tract — to  cancer  of  the  stomach,  pan- 
creas, intestines,  and  rectum  in  both  sexes,  and  to  cancer  of 
the  breast  in  the  female.  The  period  of  maximum  prevalence 
for  the  disease  of  the  liver  and  stomach  is  from  G5  to  75  and 
for  the  intestines  and  rectum  from  75  to  85. 

The  table  further  show^s  that  for  males  cancer  of  the  stomach 
and,  next  to  that,  cancer  of  the  liver,  causes  most  deaths  at  each 
age-period  after  35.  Cancer  of  the  rectum  takes  third  place, 
except  at  the  latest  age-period,  when  cancer  of  the  face  causes 
rather  more  deaths.  In  women,  as  in  men,  apart  from  the  re- 
productive system,  the  stomach  and  liver  come  first.  The 
reproductive  system  holds  an  exceptional  position  for  the  fe- 
male sex ;  the  uterus  is  the  principal  seat  of  the  disease  up  to  65, 
the  stomach  from  65  to  75,  and  the  breast  after  75.  The  total 
mortality  from  cancer  of  the  uterus  is  much  higher  than  that 
from  any  other  organ  in  either  sex,  and  more  than  half  the 
victims  are  under  55  years  of  age.  For  cancer  of  the  breast 
40  per  cent,  are  under  55.  The  table  shows  that  in  the  first  two 
age-periods  for  women,  as  many  as  22.8  and  36.0  per  cent,  of  all 
deaths  of  women  from  cancer  are  due  to  cancer  of  the  uterus, 
whereas  during  this  period  cancer  of  the  breast  is  causing 
only  9.2  and  19.2  of  the  total  deaths.  During  the  last  two 
age-periods  the  position  is  reversed,  uterine  cancer  showing 
only  11.4  and  9.5,  as  against  17.7  and  27.3  for  mammary 
cancer. 

For  some  organs  there  are  two  periods  of  maximum  inci- 
dence. The  table  shows,  with  reference  to  the  breast,  that 
these  periods  are  35  to  55,  and  after  75,  with  an  intermediate 
period  at  which  the  disease  is  less  common  in  that  organ  than 
elsewhere.  Bashford  and  Murray  ^  had  already  directed  at- 
tention to  the  occurrence  of  such  a  double  fluctuation  for  sar- 
comata in  general,  there  being  a  maximum  at  birth  and  another 
after  45,  and  also  to  the  existence  of  a  similar  phenomenon  for 
the  curious  mixed  tumors  of  the  kidney  and  adrenal. 

An  important  point  brought  out  by  the  table  is  the  large  per- 
centage of  deaths,  viz.,  64.2  and  41,  which  occur  from  cancer 
of  other  organs  in  the  earliest  period  with  a  subsequent  diminu- 
tion for  other  age-periods. 

1 ' '  The  Statistical  Investigation  of  Cancer, ' '  Toe.  cit. 


80  THE    CANCER    PROBLEM 


OCCTIPATIONAL    MORTALITY    FROM    CANCER 

The  question  of  occupational  mortality  from  cancer  cannot 
be  taken  as  settled.  Newsholme  ^  summarized  the  subject  as 
follows,  and  recent  years  have  added  little  that  is  new. 

"The  death-rates  from  cancer  in  men  aged  twenty-five  to 
sixty-five,  in  each  occupation,  are  stated  as  proportional  figures, 
groups  of  men  having  the  same  proportion  living  at  each  age 
between  twenty-five  and  sixty-five  being  compared,  and  the  re- 
sult called  'comparative  mortality  figures.'  Thus  stated,  the 
number  of  males  that  would  give  1,000  deaths  in  the  general 
population  in  1881-90  would  give  47  deaths  from  cancer. 
Among  all  occupied  males  the  comparative  mortality  figure 
from  cancer  was  44;  among  all  unoccupied  males,  96.  Among 
clergymen  and  ministers  cancer  is  represented  by  the  com- 
parative mortality  figure  35,  lavryers  by  60,  medical  prac- 
titioners 43,  commercial  travelers  63,  coachmen  and  grooms  58, 
seamen  in  the  merchant  service  60,  dock  and  wharf  laborers  51, 
porters  48,  farmers  36,  fishermen  46,  maltsters  61,  brewers  70, 
inn-keepers  53,  inn-keepers  in  London  70,  inn  and  hotel  serv- 
ants 65,  tobacconists  51,  fishmongers  42,  grocers  34,  drapers 
49,  butchers  57,  shoemakers  50,  tool,  scissors,  etc.,  makers  58, 
blacksmiths  45,  plumbers  53,  potters  35,  coal  miners  36,  coal- 
heavers  56,  gas-works  service  59,  general  laborers  48,  chimney- 
sweeps 156.  The  above  have  been  selected  from  a  much  larger 
list.  The  contrasts  are  very  striking  and,  in  some  respects,  in- 
explicable. The  theory  that  excessive  nervous  strain  and  anx- 
ious work  provoke  cancer  does  not  receive  support  in  the  fact 
that  the  comparative  mortality  figure  for  medical  men  is  only 
43,  while  it  is  as  high  as  70  for  brewers.  The  contrast  between 
lawyers  (60)  and  clergjinen  (35)  is  great;  and  although  the 
latter  may  be  supposed  to  possess  an  unusual  amount  of  free- 
dom from  mental  harass,  the  former,  with  their  long  vacations,^ 
cannot  be  said  to  suffer  exceptionally  from  such  harass. 
Chimney-sweeps  occupy  a  supremely  high  position  in  mortality 
from  cancer.  It  would  appear  that  the  irritating  effect  of  the 
products  of  imperfect  combustion  of  coal  is  much  more  prone 
to  bring  out  cancerous  activity  than  the  manipulation  of  the 
crude  coal,  though  coal-heavers  have  a  somewhat  high  propor- 

1  Newsholme,  Arthur. — "The  Statistics  of  Cancer,"  The  Practitioner, 
April,  1899,  Vol.  LXTI,  N.  S.  IX,  p.  371. 

^  Newsholme  refers  to  England.  The  Royal  Courts  of  Justice  opened 
on  October  13,  1913,  after  a  recess  of  ten  weeks,  for  another  working 
' '  year ' '  of  some  six  months.  There  are  long  holidays  at  Christmas  and 
Easter. 


STATISTICAL    CONSIDERATIONS  81 

tional  amount  of  cancer.  The  low  cancerous  figure  for  coal- 
niiners  indicates  that  they  enjoy  a  comparative  immunity  from 
cancer  as  well  as  from  phthisis.  Can  any  reasonable  hypothesis 
be  framed  to  explain  why  the  manipulation  of  coal  under- 
ground should  be  so  much  less  irritating  than  its  manipulation 
above  ground  ?  Can  it  be  that  we  have  to  look  to  intemperate 
habits  as  being  a  main  factor  at  work  rather  than  the  particular 
occupation?  The  figures  for  commercial  travellers,  coachmen, 
seamen,  brewers,  maltsters,  inn-keepers,  and  butchers  certainly 
point  in  this  direction.  The  figures  for  chimney-sweeps,  ap- 
pear, however,  to  stand  in  separate  and  independent  category." 

Statistics  have  since  been  published,  giving  the  experience 
of  some  insurance  societies,  appearing  to  show  that  the  idea  of 
the  prejudicial  influence  of  alcohol  may  have  some  basis  on 
fact,  but  it  is  still  a  moot  point  whether  this  is  true  or  not.  In 
the  case  of  the  alimentary  canal,  at  any  rate,  this  possibility  has 
been  practically  established  by  the  greater  frequency  with 
which  males  suffer  from  cancer  of  the  upper  half  of  the  ali- 
mentary canal  and  stomach,  especially  in  occupations  prone  to 
alcoholic  indulgence,  as  well  as  by  the  custom  of  some  in- 
surance companies  which  make  a  distinction  in  the  premiums 
paid  by  the  total  abstainer,  and  even  by  those  who  indulge  mod- 
erately in  alcohol. 

As  regards  chimney-sweeps,  there  seems  to  be  no  doubt  that 
their  liability  to  cancer  of  the  scrotum  is  directly  attributable 
to  soot.  Butlin  ^  has  pointed  out  the  different  liability  of 
chimney-sweeps  on  the  continent  of  Europe  where  care  is  taken 
to  preclude  entrance  of  soot  under  the  clothing,  and  where 
great  cleanliness  is  observed.  Whether  the  soot  acts  as  a  physi- 
cal or  a  chemical  irritant  is  not  settled.  Its  relation  to  can- 
cer is  paralleled  by  the  occurrence  of  warts  on  the  skin  in 
pitch  and  paraffin  workers.  The  liability  of  such  warts  to 
malignant  degeneration  has  led  to  special  legislation  in  Eng- 
land. Of  other  well-defined  irritants,  mention  may  be  made  of 
the  frequency  of  papilloma  of  the  bladder  in  aniline  workers. 

All  these  exceptional  accumulations  of  cancer  on  particular 
parts  of  the  body  are  of  the  greatest  etiological  significance, 
and  point  to  real  differences  in  the  frequency  and  distribution 
of  cancer  in  different  populations.  Their  importance  is  en- 
hanced when  considered  together  with  the  differences  revealed 
by  the  investigations  of  the  Imperial  Cancer  Research  Fund 
in  the  distribution  of  cancer  in  primitive  races  as  the  result  of 

*  Butlin,  Sir  Henry  T. — Evidence  given  in  "Eeport  of  the  Depart- 
mental Committee  on  Compensation  for  Industrial  Diseases,"  London, 
1907. 


82  THE    CANCER    PROBLEM 

the  practice  of  customs  which  lead  to  irritation  of  particular 
parts  of  the  body. 

IS    CANCER    INCREASING? 

The  question  whether  or  not  cancer  is  increasing  can  only 
be  briefly  reviewed  within  the  limits  of  this  volume.  In  Eng- 
land almost  as  soon  as  statistics  had  developed  sufficiently  to 
show  the  efl'ects  of  sanitary  reform,  i.  e.,  toward  the  middle  of 
last  century,  it  became  apparent  that  the  statistics  of  mortality 
from  cancer  were  not  taking  the  same  downward  course  as  were 
those  of  mortality  from  epidemic  diseases.  With  the  estab- 
lishment of  this  fact  there  w^as  precipitated  the  long  debate, 
which  still  continues,  as  to  whether  the  increase  in  the  number 
of  deaths  recorded  from  cancer  is  real  or  only  apparent.  The 
phenomenon  is  universal  wherever  statistics  are  available 
throughout  the  M^orld. 

The  faddists  who  do  not,  or  who  cannot  discuss  the  figures 
and  statistics  recording  the  apparent  or  real  increase  may  be 
dismissed  summarily.  For  the  most  part  they  accept  the  view 
of  a  real  increase  because  it  suits  their  propaganda  against  the 
consumption  of  tea,  coffee,  butcher's  meat,  or  any  other  circum- 
stance in  diet  or  habits  of  life  which  happens  to  be  their  pet 
aversion.  Their  arguments  would  apply  with  equal  force  to 
the  improved  sanitation  which  the  last  fifty  years  has  seen,  or 
to  the  development  of  aviation,  as  being  responsible. 

As  regards  the  consumption  of  meat — chilled  or  frozen  meat 
being  especially  singled  out  for  condemnation — it  may  be  noted 
that  the  increase  in  the  deaths  recorded  from  cancer  in  England 
was  apparent  long  before  chilled  or  frozen  meat  reached  that 
country  in  any  quantity,  or  toward  the  end  of  the  seventies  of 
the  last  century. 

The  cooking  of  vegetables  and  fruits  is  blamed,  but  surely 
vegetables  and  fruits  were  cooked  long  before  the  increase  of 
cancer  revealed  itself,  and  therefore  cannot  be  held  responsible. 
The  number  of  deaths  recorded  among  vegetarian  castes  in 
India,  who  were  formerly  alleged  to  be  exempt,  is  not  due  to 
any  change  in  their  habits,  but  ' 'because  the  disease  has  been 
looked  for  and  found,"  as  Bashford  tersely  puts  it  in  the  case  of 
the  mouse  and  the  cow.  What  is  there  in  the  life  of  a  mouse 
or  cow  to-day  which  differs  from  that  of  ten  years  ago  when  no 
cancer  was  known  in  the  mouse  and  only  the  expert  knew  of  a 
few  cases  in  the  cow,  as  contrasted  with  the  thousands  of  cases 
now  on  record  ?  In  Japan,  where  the  habits  of  the  people  gen- 
erally have  undergone  no  change  as  regards  diet,  the  phenom- 


STATISTICAL    CONSIDERATIONS 


83 


enon  of  the   increase   of  cancer   presents  itself  also   in  their 
national  statistics. 

To  turn  to  the  serious  consideration  of  whether  the  increase 
is  real  or  not,  on  the  one  hand  it  is  urged  that  the  improvements 
in  the  certification  of  the  causes  of  death  and  in  the  diagnosis  of 
cancer  do  not  suffice  to  explain  the  recorded  increase.  Many 
who  hold  this  view  also  advocate  that  cancer  is  infectious.  On 
the  other  hand,  it  is  said  that  these  factors  do  suffice  to  explain 
all  the  increase,  since  this  is  mainly  an  increase  of  internal 
cancer,  and  since  it  is  much  greater  in  men  than  in  women,  ow- 
ing to  female  cancer  being  more  readily  accessible  to  complete 
clinical  examination.  If  the  increase  were  real,  there  is  no 
apparent  reason  why  it  should  affect  men  more  than  women. 
It  is  urged  further  that  the  increase  affects  mainly  the  higher 
age-periods.  These  features  of  the  increase  are  brought  out  in 
the  accompanying  table  from  ISTewsholme,^  and  it  is  difficult  to 
reconcile  the  facts  with  such  hypothetical  causes  as  the  con- 
sumption of  tea,  coffee,  meat,  or  cooked  vegetables. 

Death-rates  from  Cancer  per  Million  Living  in  Each  Age-period, 
1861-70  and  1896. 


Periods 

All 
ages 

0- 

5- 

10- 

15- 

20- 

25- 

35- 

45- 

55- 

65- 

75  and 

up- 
wards 

Males. 

Death-rates  1861-70 
1869... 

242 
618 

13 

27 

8 
23 

7 
19 

18 
42 

26 

48 

60 

89 

204 
419 

536 
1,362 

1,201 
3,340 

1,862 
5,427 

2,258 

5,992 

Percentage    increase 
between    1861-70 
and  1896 

155 

109 

192 

175 

137 

86 

49 

106 

154 

179 

177 

165 

Females. 

Death-rates  1861-70 
1896.. . 

519 
901 

13 
32 

7 
11 

7 
11 

16 
30 

32 
42 

161 
175 

669 
933 

1,530  2,291 

2,308  4,187 

2,791 
5,686 

2,786 
6,539 

Percentage    increase 
between    1861-70 
and  1896 

74 

150 

60 

60 

91 

33 

9 

40 

51 

83 

104 

135 

King  and  !N^ewsholme^  emphasized  the  necessity  for  con- 
sidering the  parts  of  the  body  separately,  according  as  they  are 

1 ' '  The  Statistics  of  Cancer, ' '   Joe.  cit. 

'  King,  George,  and  Newsholme,  Arthur. — ' '  On  the  Alleged  Increase  of 
Cancer, ' '  Proc.  Eoy.  See.  of  London,  Vol.  54,  1893,  p.  209. 


84 


THE    CANCER    PROBLEM 


accessible  or  inaccessible  to  physical  examination.  EasLford 
reinforced  Xewsliohne's  ari;\nnents,  with  the  result  that  even 
this  recommendation  was  improved  upon,  and  the  collaboration 
of  the  Kegistrar-Generars  Office  and  the  Imperial  Cancer  Re- 
search Fund  resulted  in  tlie  tabulation  of  all  the  deaths  from 


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Fig.  3. — Analysis  of  cancer  for  women.  Shows  absence  of  increase  for 
skin,  uterus,  ovary,  liver,  and  gall-bladder,  and  increase  for  breast, 
stomach,    intestines,    rectum.     (After   Registrar-General   for   England.) 


cancer  for  each  single  site  separately  for  a  period  of  ten  years. 
In  this  way  the  enigma  of  the  increase  in  the  number  of  deaths 
recorded  from  cancer  in  general  has  been  once  and  for  all  re- 
solved into  simpler  problems  for  each  part  of  the  body.     The 


STATISTICAL    CONSIDERATIONS 


85 


table  given  on  page  73  shows  how  baffling  was  the  increase  of 
cancer  in  general  as  contrasted  with  the  simplicity  of  the 
problem  presented  by  the  two  accompanying  curves  (Figs.  3 
and  4)  for  separate  parts  of  the  body.  The  results  have  been 
summarized  as  follows :  ^ 


195 


00 


o 

_ 

r^ 

o 

o 

O 

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0) 

0) 

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o 

o 

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ISO 
165 
150 
135 
0,20 

.    90 

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j 
30 

} 
15 


>• 

^ 

^ 

X 

y 

/ 

Sto 

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h 





^ 

.^ 



Z/i 

^er  t 

iGa, 

1  Bk 

idde 

r 

^♦" 

•  •• 

*  •« 

.»••*' 

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,4^ 

^•^ 

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led 

um 

_ ,  -  .^ 

— .— 



''' 

-'^•- 

1^ 

$un' 

s-s 

^ 

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re 

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Sk/r 

Fig.  4. — ^Analysis  of  the  increase  of  cancer  for  men.  Shows  absence  of 
increase  for  skin,  Uver  and  gall-bladder  and  increase  for  tongue,  stomach, 
rectum,  intestines.     (After  Registrar-General  for  England.) 

"^For  several  reasons  it  has  long  been  desired^  that  the 
reports  of  the  Registrar-General  should  contain  detailed  in- 
formation on  the  incidence  of  cancer  in  different  parts  of  the 

1  Introduction,  Fourth  Scientific  Eeport  of  the  Imperial  Cancer  Research 
Fund,  1911. 

'  The  first  serious  attempt  to  attain  this  end  was  made  by  the  late 
Sir  Henry  T.  Butlin :  ' '  Proposed  letter  to  the  Registrar-General  for  Eng- 
land of  Births,  Deaths  and  Marriages  on  the  subject  of  the  increase  of 
Cancer,  drawn  up  by  Mr.  Butlin,  of  which  the  following  is  a  copy, ' '  Pro- 
ceedings of  Council,  Brit.  Med.  Jour.,  November  12,  1887,  p.  1070;  King, 
George,  and  Newsholme,  Arthur,  "On  the  Alleged  Increase  of  Cancer," 
\oc.  cit. 


86  THE    CANCER    PROBLEM 

body,  and  Dr.  Tatham  was  able  to  make  arrangements  for  ob- 
taining this  information  at  the  outset  of  these  investigations. 
The  application  of  the  law  of  age-incidence  of  cancer  to  short- 
lived as  well  as  to  long-lived  animals,  reinforced  the  other  rea- 
sons for  obtaining  it,  and  suggested  that  knowledge  would  be 
advanced  by  more  detailed  information  about  the  age-incidence 
of  cancer  in  the  several  organs  of  man  as  distinct  from  its  de- 
pendence on  the  age-distribution  of  persons.^  It  was  antici- 
pated that  the  data  would  be  of  both  biological  and  statistical 
value,  and  the  facts  published  by  Dr.  Stevenson  in  the  last 
report  of  the  Registrar-General  show  that  this  hope  has  been 
fulfilled  in  several  directions. 

''The  new  tabulation  of  the  data  for  the  years  1901-09,  for 
England  and  Wales  has  permitted  an  analysis  being  made  of 
the  figures  recording  the  increase  of  deaths  attributed  to  cancer, 
which  brings  out  the  fact  that  the  increase  during  this  period 
is  i-eferable  to  certain  anatomical  regions  and  not  to  others. 
Thus,  for  males  the  main  increase  falls  on  the  alimentary  tract, 
especially  the  stomach.  The  liver  and  gall-bladder  and  the 
skin  show  no,  or  only  a  slight,  increase.  For  females  the 
increase,  although  it  falls  mainly  on  the  alimentary  tract 
(stomach  and  intestines),  affects  also  the  mamma,  while  the 
uterus,  ovary,  liver  and  gall-bladder,  rectum  and  skin  show 
little  or  no  increase.  It  is  also  of  importance  that  the  recorded 
mortality  from  cancer  of  the  generative  organs  has  not  in- 
creased at  the  same  rate  as  that  for  other  organs,  and  that  most 
of  the  increases  affect  the  higher  age-periods  predominantly. 

"For  the  first  time  it  is  fully  demonstrated  that  it  is  errone- 
ous to  make  statements  of  a  disquieting  nature  about  the  in- 
crease of  cancer  in  general.  In  conjunction  with  investiga- 
tions^ into  the  errors  of  diagnosis  among  hospital  patients, 
means  are  afforded  of  determining,  for  parts  of  the  body  where 
the  disease  appears  to  be  increasing,  whether  the  increase  is 
real  or  only  apparent,  and  of  ascertaining  the  causal  factors 
peculiar  to  such  parts.  While  it  is  evident  that  several  of  the 
differences  brought  out  by  the  figures  can  be  explained  by  more 
accurate  diagnosis  and  by  allocation  of  the  seat  of  the  disease 
from  the  secondary  to  the  primary  situations,  as  illustrated, 

1  Bashford,  E.  F.,  and  Murray,  J.  A.:  "The  Statistical  Investigation  of 
Cancer, ' '  Second  Scientific  Report  of  the  Imperial  Cancer  Eeseareh  Fund, 
Part  I,  pp.  3,  24,  and  51. 

'  Comparison  of  the  clinical  diagnosis  with  the  results  of  pathological 
and  microscopical  examination.  See  Second  Scientific  Report  of  the 
Imperial  Cancer  Research  Fund,  Part  I,  pp.  18-24;  Bashford,  E.  F. : 
Address  on  Cancer  in  Man  and  Animals.  General  Meeting  of  the  XVIth 
International  Medical  Congress,  Budapest,  1909,  and  in  The  Lancet, 
September  4,  1909,  p.  694;  Berl.  Jslin.  Woch.,  1909,  Nos.  36  and  37. 


STATISTICAL    CONSIDERATIONS  87 

e.  g.,  by  the  relation  revealed  between  cancer  of  the  liver  and 
gall-bladder  and  the  alimentary  tract,  this  may  not  account 
fully  for  certain  other  features.  In  particular,  the  increased 
incidence  of  cancer  recorded  for  the  mamma  in  women,  and  the 
tongue  in  men,  requires  further  study  and  elucidation. 

"The  analysis  also  shows  that  the  incidence  is  very  unequally 
distributed  among  the  several  situations,  indeed,  that  the  whole 
curve  of  incidence  may  be  different  for  different  organs.  A 
progressive  increase  up  to  the  highest  age-periods  is  character- 
istic of  the  face,  lip,  mouth,  bladder,  urethra,  and  breast  only. 
The  other  organs  show  a  distinct  diminution  in  the  highest 
age-periods ;  but  it  is  not  yet  possible  to  determine  whether  this 
curve  indicates  a  liability  rising  to  a  maximum  and  followed 
by  a  fall,  or  is  merely  the  result  of  ascribing  deaths  to  other 
causes  in  the  case  of  cancer  of  internal  organs  in  aged  people. 
The  proportion  of  total  deaths  ascribed  to  the  ill-defined  cause 
of  old  age  is  65.6  per  1,000  deaths  from  all  causes  as  com- 
pared with  65.7  for  cancer,  and  it  must  be  borne  in  mind  that 
the  increases  recorded  for  cancer  affect  principally  the  higher 
age-periods,  and  that  the  average  age  of  the  population  is  in- 
creasing [see  below].  Sufficient  has  been  said  to  indicate  how 
important  are  the  problems  which  are  solved  or  revealed  by  the 
improvement  in  the  details  given  in  the  national  statistics. 

"The  study  of  the  occurrence  of  cancer  in  mankind,  and  in 
domesticated  animals  in  widely  separated  parts  of  the  globe,  has 
shown  that  the  practice  of  peculiar  customs  (involving  the  ap- 
plication of  chronic  irritants  to  particular  parts  of  the  body) 
provokes  the  disease  in  situations  and  organs  from  which  it  is 
absent  when  these  customs  do  not  obtain.  It  is  reasonable  to 
suppose  that  the  frequency  of  cancer  would  be  diminished  if 
such  practices  as  the  use  of  the  Kangri  in  Kashmir,  chewing 
betel-nut  in  India,  and  eating  very  hot  rice  in  China,  were  dis- 
continued. It  is  also  reasonable  to  assume  that  the  introduc- 
tion into  England  of  these  exotic  customs  would  greatly  in- 
crease the  frequency  of  cancer  in  this  country." 

If  the  numbers  living  in  1881  at  each  quinquennial  age- 
period  be  reckoned  as  percentages  of  those  living  at  the  same 
age-periods  in  1911,  see  pages  88  and  89,  obtained 
from  the  Census  of  England  and  Wales  in  1911,^  show  that 
the  proportion  of  the  population  in  the  cancer-ages  was  much 
smaller  thirty  years  ago  at  all  age  periods  except  one.  This 
phenomenon  of  itself  will  account  for  an  increase  in  the  abso- 

1  Census  of  England  and  Wales,  1911,  Vol.  VII.  Ages  and  Condition 
as  to  Marriage.     London,  1913. 


88 


THE    CANCER    PROBLEM 


lute  number  of  deaths,  although  not  for  the  apparent  relative 
increase.     {Fig'  5.) 

Ratio  of  the  Proportional  Number  Enumerated  at  Each  Age-period  in  1881  to 
the  Corresponding  Number  in  1911  Taken  as  100. 


Agea 

1881 

1911 

Ages 

1881 

1911 

Under  5  years 

127 
118 
111 

106 

102 

92 

84 
82 
87 

100 
100 
100 
100 
100 
100 
100 
100 
100 

45  and  under  50  years .  .  . 
50  and  under  55  years . .  . 
55  and  under  60  years .  .  . 
60  and  under  65  years .  .  . 
65  and  under  70  years .  .  . 
70  and  under  75  years .  .  . 
75  and  under  80  years . .  . 
80  and  under  85  years . .  . 
85  and  upwards 

83 
89 
88 
99 
86 
88 
91 
92 
83 

100 

5  and  under  10  years .  .  . 
10  and  under  15  years .  .  . 
15  and  under  20  years .  .  . 
20  and  under  25  years .  .  . 
25  and  under  30  years .  .  . 
30  and  under  35  years .  .  . 
35  and  under  40  years .  .  . 
40  and  under  45  years .  .  . 

100 
100 
100 
100 
100 
100 
100 
100 

In  the  most  recent  Report  of  the  Registrar-General  for  Eng- 
land and  Wales,  that  for  1911,  published  in  1913,  the  stand- 
point taken  is  siunmarized  as  follows : 

"While  the  figures  for  a  single  year  would  be  far  too  small  a 
basis  for  forming  a  definite  conclusion  on  this  matter,  and  there 
is  evidence  pointing  to  a  real  increase  of  cancer  of  certain  parts 
of  the  body  (Report  for  1909,  p.  XCIII),  the  figures  for  1911 
seem  to  harmonize  sufficiently  well  with  the  hypothesis  that 
recorded  differences  in  mortality  depend  upon  varying  degrees 
of  accuracy  in  diagnosis  to  make  it  worth  while  to  watch  those 
of  subsequent  years  from  the  same  point  of  view.  If  these 
latter  point  in  the  same  direction,  then  we  must  ask  ourselves 
whether  England  and  Wales  in  1911  do  not  compare  with 
England  and  Wales  in  1881  more  or  less  as  London  in  1911 
does  with  the  rural  districts  in  1911.  The  peculiar  history 
of  the  increase  of  cancer  mortality  in  regard  to  age  and  sex 
would  then  be  explained.  The  records  show  continuous  in- 
crease at  all  ages  for  males,  whereas  in  females  the  increase 
at  ages  35-45  ceased  about  20  years  ago,  and  more  recently 
that  at  45-55.  At  the  latter  age-periods  the  increase  still  con- 
tinues at  rates  which  increase  in  rapidity  with  increase  of 
age.  The  male  increase  at  all  ages  would  be  explained  by 
the  fact  that,  taking  the  country  as  a  whole,  there  is  still 
considerable  room  for  improvement  in  diagnosis  at  every  age 
in  males.  The  cessation  of  increase  in  middle-aged  women 
is  explained  if  we  assume  that  cancer,  being  better  diagnosed 
in  the  female  sex  and  at  the  earlier  ages,  is  now  seldom  over- 
looked in  middle-aged  females,  although  it  formerly  was  so,  the 
frequency  of  occurrence  being  assumed  constant.  Probably  there 
is  little  doubt  that  cancer  is  more  easily  diagnosed,  because 


STATISTICAL    CONSIDERATIONS 


89 


more  accessible,  in  females,  but  the  assumption  that  it  is  more 
frequently  overlooked  in  old  than  in  middle  age  is  more  open 
to  qviestion.  ...  It  seems  natural,  however,  that  in  the  case  of 
persons  M^hose  age  alone  suffices  to  explain  failure  of  their  vital 


35 


4-0       45        50 


55      eo 


e5> 


TO       75        SO      85 


lUU  ■ 

/ 

S70 

/ 

y" 

\ 

.0 
+^ 

85 

\ 

/ 

\ 

/ 

/ 

\ 

/ 

\ 

Fig.  5. — This  chart  indicates  diagrammatically  the  increase  in  the  age  of 
the  population  of  England  and  Wales.  The  year  1911  is  here  taken  as 
standard  for  each  age-period  and  is  reckoned  as  100  living  for  each  age- 
period.  The  fluctuating  line  indicates  how  many  were  Uving  in  pro- 
portion thirty  years  earlier. 


povrers  the  search  into  the  cause  of  obscure  illness  should  at 
times  be  less  rigorous  than  is  felt  to  be  demanded  vrhen  a  per- 
son of  middle  age  is  concerned,  whose  span  of  life  is  clearly  cut 
short  by  definite  illness  of  some  kind." 

It  would  thus  seem  that  the  long  debate  as  to  the  meaning 


90 


THE    CANCER    PROBLEM 


of  the  increase  in  the  number  of  deaths  recorded  from  cancer 
was  to  end  by  admitting  the  possibility  of  increase  for  some 
parts  of  the  body,  and  in  pointing  very  definitely  to  the  lines 
■along  which  statistical  research  may  be  pursued  with  profit. 
This  result  has  been  attained,  not  by  compiling  special  sta- 
tistics of  cancer  by  means  of  a  "cancer-census,"  but  by  improv- 
ing national  mortality  statistics  as  a  whole,  and  especially  by 
considering  those  of  cancer  as  an  important  part  of  all,  as  ad- 
vocated and  successfully  carried  through  in  England  largely 
at  the  instigation  of  Bashford,  and  as  the  result  of  his  argu- 
ments, based  upon  the  comparative  study  of  cancer  in  mankind 
and  animals,  and  upon  experimental  investigations. 


CANCER    MORTALITY    ACCORDING    TO    LOCALITY 

The  relative  frequency  of  cancer  in  town  and  country  calls 
for  brief  reference.  Everywhere  the  diagnosis  and  treatment 
of  disease  and  certification  of  causes  of  death,  are  backward  in 
the  country  as  compared  with  the  towns.  It  is  therefore  not 
surprising  that  cancer  is  more  frequently  recorded  in  towns 
than  in  the  country.  That  this  may  be  largely  the  explanation 
is  supported  by  the  fact  that  it  cannot  be  shown  that  over- 
crowding in  the  towns  has  any  influence  upon  the  death-rate 
from  cancer.  In  all  such  questions  of  relative  frequency  in  one 
area,  as  contrasted  with  another,  the  question  of  the  relative 
proportions  of  each  sex  and  the  numbers  of  each  living  at  the 
several  age-groups  is  important.  This  fact  was  brought  out 
some  years  ago  by  King  and  Newsholme  ^  in  a  striking  com- 
parison between  England  and  Ireland.  The  importance  of  the 
correction  of  cancer  mortality  for  varying  age-distribution  of 
populations  is  particularly  great  when  comparisons  are  made 
between  different  countries,  or  even  between  the  different  coun- 
ties of  England. 


Comparison 

of  Corrected  and 

Uncorrected 

Death-rates 

Period 

Not  Corrected 

Corrected 

England 

Ireland 

England 

Ireland 

1860-66 

498 
597 
719 
902 
1,091 

553 
627 
680 
807 
894 

825 

747 

911 

1,152 

1,393 

614 

1867-73 

661 

1874-80 

699 

1881-87 

824 

1888-90 

912 

^  King  and  Newsholme. — ' '  On  the  Alleged  Increase  of  Cancer, ' '  loc.  cit. 


STATISTICAL    CONSIDERATIONS  91 

It  will  be  observed  that,  by  the  uncorrected  figures,  Ireland 
stands  a  little  above  England  for  the  first  two  periods,  and  a 
little  below  it  for  the  other  three,  but  that  no  very  great  dif- 
ference appears  between  the  rates  for  the  two  countries.  The 
corrected  figiires,  however,  show  that  Ireland  stands  below  Eng- 
land throughout,  so  that  in  the  first  two  periods  the  position  of 
the  countries  is  reversed  by  the  correction,  and  in  the  last  three 
periods  the  difference  in  favor  of  Ireland  is  very  great  indeed. 
It  is  evident  that  the  ordinary  method  of  presenting  statistics 
exaggerates  the  rate  of  cancer  in  Ireland  as  compared  with 
England,  a  result  which  might  have  been  expected,  owing 
to  the  age-distribution  of  the  populations  of  the  two  coun- 
tries. 

The  fallacy  here  revealed  when  age  alone  is  concerned — sex 
being  left  out  of  account — probably  also  invalidates  all  the 
statements  that  have  been  made  as  to  the  relative  frequency  of 
cancer  in  different  states  in  America,  and  in  different  races, 
whether  Indian,  black  or  white,  or  of  Teutonic,  English,  or 
Latin  descent,  more  especially  because  persons  are  considered 
and  no  allowance  is  made  for  the  relative  proportions  of  the 
two  sexes  at  the  several  age-groups.  This  criticism  applies 
especially  to  the  map  (Fig.  2,  page  76)  which  McConnell 
has  constructed  for  America.  This  map  is  quite  valueless  be- 
cause it  is  based  upon  a  stateraent  of  the  deaths  in  different 
state  groups  per  1,000  deaths  from  all  knov\m  causes,  which  is 
well  known  to  be  a  fallacious  method.  An  epidemic  of  measles 
among  children,  for  example,  would  upset  the  whole  calculation 
by  lowering  the  death-rate  from  cancer. 

Hoffman  ^  has  recently  published  figures  which  he  claims 
show  the  liability  of  the  negro  and  white  populations  in  the 
South,  and  a  change  in  the  liability  of  the  negro  population. 
These  figures  are  not  considered  here  in  detail  because  the 
Census  Bureau  points  out  in  the  "Physicians'  Pocket  Refer- 
ence" that  the  South  has  hitherto  been  entirely  unrepresented 
by  reliable  state  registration. 

RELATION    OF    STATISTICS    TO    ETIOLOGY 

It  is  well  recognized  that  statistics  should  not  be  expected 
to  prove  the  cause  of  any  disease.  They  have  often  given  im- 
portant indications  of  the  line  of  advance ;  they  have  likewise 
exploded  fallacious  views  of  etiology. 

*  Hoffman,  Frederick  L. — '  *  The  Menace  of  Cancer, ' '  Am.  Jour,  of  Ob- 
stetrics and  Bis.  of  Women  and  Children,  1913,  68,  p.  88;  Trans.  Am.  Gyn. 
Soc,  1913. 


92  THE    CANCER    PROBLEM 

The  late  Doctor  Roswell  Park,^  iu  an  address  before  the  In- 
ternational Surgical  Congress,  Brussels,  1908,  summarized  as 
follows  his  position  with  reference  to  the  infectivity  and  treat- 
ment of  the  disease : 

* 'Holding  to  these  views,  cancer  must  be  treated  much  as  we 
would  treat  a  filth  disease,  especially  when  it  has  advanced  to 
the  ulcerative  stage,  namely  by  the  most  efficient  cleanliness. 
Cremation  should  supersede  earth  burial,  and  all  soiled  dress- 
ings and  discharges  should  be  destroyed  by  fire,  while  rooms 
and  even  houses  inhabited  by  cancer  patients  should  be  most 
thoroughly  disinfected,  both  during  illness  and  after  death." 

These  statements  did  not  meet  with  any  response  from  the 
Congress,  but  their  echo  has  reached  the  American  public,  and 
such  views  have  been  widely  spread  among  the  ignorant,  leading 
them  to  demand  that  all  furniture,  bedding,  etc.,  be  burned. 

A  moment's  reflection  on  what  statistics  have  proved  for  the 
infective  diseases,  or,  to  use  the  exact  term,  ''filth  diseases" — 
if  typhus  fever  be  taken  as  the  filth  disease  par  excellence — 
shows  that  sanitation  has  effected  their  marked  reduction,  and 
in  the  case  of  the  typical  filth  disease,  typhus  fever,  its  ex- 
tinction, except  where  filth  still  obtains.  This  diminution  in 
the  infective  or  filth  diseases  has  not  been  shared  by  cancer. 
It  follows,  therefore,  that  cancer  conforms  to  other  laws  than 
those  governing  the  occurrence  and  spread  of  filth  diseases  in 
the  community. 

It  should  not  be  inferred,  of  course,  that  disinfection  should 
not  be  practised  for  the  sake  of  cleanliness,  and  for  the  pur- 
pose of  allaying  the  fears  of  the  timid;  but  only  that  those 
forms  of  disinfection  which  are  efficacious  for  dangerous  in- 
fective diseases,  such  as  smallpox,  should  suffice  to  overcome 
any  reasonable  or  unreasonable  anxiety. 

Statistics  dispose  in  yet  another  way  of  alarming  statements 
such  as  the  one  quoted  from  Park.  The  enormously  over- 
crowded and  filthy  conditions  obtaining  in  parts  of  New  York 
and  London  might  be  expected,  in  accordance  with  this  view,  to 
be  hotbeds  for  breeding  cancer,  but  there  is  no  evidence  of  this 
being  the  case.  Unfortunately  there  are  no  actual  statistics 
which  can  be  quoted  for  New  York,  but  extremely  valuable  sta- 
tistics are  available  for  the  different  parts  of  London.  The 
highest  cancer  death-rate  occurs,  not  in  the  slums  of  White- 
chapel,  but  in  Hampstead,  the  highest  lying  suburb  in  London 
and  the  wealthiest  residential  section  of  the  city,  consisting  of 

*Park,  Roswell. — "The  Nature  of  the  Cancerous  Process,"  11  Congres 
de  la  Societe  Internationale  de  Chirurgie,  Brussels,  Sept.  21-25,  1908,  Vol. 
II,  pp.  321  and  338. 


STATISTICAL    CONSIDERATIONS  93 

large  villa  residences  in  private  grounds.  There  is  no  support 
found  here  for  the  view  that  the  overcrowded  tenement  is  more 
cancer-ridden  than  the  mansion.  The  statistics  directly  refute 
any  relation  between  overcrowding-filth  and  a  higher  incidence 
of  cancer.  Again,  New  York  must  be  passed  over,  for  there 
are  no  available  figures.  In  Vienna,^  Stuttgart,^  and  London  ^ 
the  relation  between  cancer  and  overcrowding  has  been  care- 
fully investigated,  and  for  all  three  it  could  not  be  shown  that 
overcrowding  had  any  effect — indeed,  in  London  there  was 
more  cancer  in  the  least  densely  populated  areas. 

In  view  of  such  facts  as  the  above  the  public  has  a  right  to 
demand  that  they  shall  not  be  made  unduly  anxious  by  wild 
and  exaggerated  statements,  and  in  this  demand  they  are  sup- 
ported by  the  effects  resulting  from  alarming  prophecies  like 
the  following,  also  made  by  Roswell  Park,  in  1899  :  ^ 

"If  for  the  next  ten  years  the  relative  death-rates  are  main- 
tained we  shall  find  that  ten  years  from  now,  viz.,  1909,  there 
will  be  more  deaths  in  New  York  State  from  cancer  than  from 
consumption,  smallpox,  and  typhoid  fever  combined." 

Apart  from  the  fact  that  this  way  of  putting  the  data  is  not 
permissible  in  connection  with  accurate  statistics,  the  subse- 
quent course  of  events  has  not  confirmed  this  prediction  for 
New  York  State,^  and  it  is  hoped  that  in  future  prophecy  will 
be  abandoned  as  a  weapon  in  scientific  controversy,  and  that  the 
public  will  consider  the  impartial  tribunal  of  statistics  to  be 
more  reliable  than  exaggerated  assertions. 

Another  aspect  of  this  same  subject  is  raised  by  statements 
concerning  "cancer  houses,"  the  occurrence  of  cancer  in  hus- 
band and  wife — so  called  cancer-d-deux — and  the  risk  of  in- 

1  Rosenf eld,  Siegfried. — ' '  Kritik  bisheriger  Krebsstatistiken  Mit  vor- 
schlagen  fiir  ein  zukiinftige  Oesterreichische  Krebsstatistik, "  Wien  and 
Lpz.,  Vienna,  1911. 

2  Weinberg  and  Gastpar. — ' '  Die  bosartigen  Neubildungen  in  Stuttgart 
1873-1902,"  Zeitsch.  f.  Krebsforschung,  Bd.  IV,  1906,  p.  18. 

3  Annual  Report  of  the  Public  Health  Committee  of  the  London  County 
Council,  1908. 

4  Park,  Roswell. — ' '  A  Further  Inquiry  into  the  Frequency  and  Nature  of 
Cancer,"  The  Practitioner,  1899,  Vol.  LXII,  N.  S.  IX,  p.  385. 

5  The  total  deaths  in  New  York  State  from  pulmonary  tuberculosis 
(consumption),  smallpox,  typhoid  fever,  and  cancer,  for  1899  and  1909 
(as  given  in  the  13th  Annual  Report  of  the  State  Dept.  of  Health,  1909, 
Vol.  I,  pp.  177-178)  are  as  follows: 

1899.  1909. 

Pulmonary    tuberculosis    13,412  13,996 

Smallpox 21  4 

Typhoid   fever 1,604  1,315 

Total 15,037  15,315 

Cancer    4,533  7,060 

Difference 10,504  8,255 


yt  THE    CANCER    PROBLEM 

fectiug  the  unborn  babe  because  the  grandmother  is  dying  of 
cancer.  The  writer  has  failed  to  find  any  reliable  statistician 
who  supports  the  risk  of  infection  in  these  ways.  This  is  not 
surprising,  in  view  of  the  fact  that  the  large  figures  available 
for  populations  are  now  forsaken  for  the  small  figures  of  indi- 
vidual experience.  The  fallacies  of  small  figures  are  notorious, 
and  the  risk  of  their  creeping  in  is  enhanced,  in  the  case  of 
cancer,  bv  the  fact  that  ultimately  it  kills  1  in  7  women  and  1 
in  11  men  above  the  age  of  35.  With  so  high  an  average  fre- 
quency in  the  general  population,  in  accordance  with  the  law 
of  probabilities,  accidental  exaggerations  of  cancer  statistics 
are  to  be  expected.  This  chance  will  be  enhanced  whenever 
the  circumstances  are  such  that  many  persons  in  a  given  locality 
attain  the  cancer-age  or  to  old  age,  as  in  the  case  of  occupants 
of  old  family  mansions,  of  agricultural  districts,  or  districts 
selected  for  habitation  by  those  retiring  from  business.  To 
have  any  significance  they  would  have  to  occur  with  great 
frequency  instead  of  the  great  rarity  with  which  they  are 
actually  recorded. 

As  regards  contact — even  less  remote  than  that  of  a  grand- 
mother with  her  unborn  gTandchild — the  figures  for  density  of 
population  deprive  it  of  all  significance,  as  indeed  also  do  the 
negative  results  of  experiments  directly  conducted  with  this 
possibility  in  view.  That  real  accumulations  of  cancer  do  occur 
is  not  denied;  it  is  only  stated  that  reliable  evidence — reliable 
from  a  statistical  point  of  view — of  contact  being  responsible 
does  not  exist.  Even  the  actual  handling  of  cancer,  as  prac- 
tised daily  by  the  surgeon  and  the  hospital  nurse,  has  been 
found  to  have  no  risks  for  either.  Nevertheless,  should  a  sur- 
geon accidentally  receive  an  injury  at  an  operation,  the  obser- 
vation is  not  infrequently  at  once  offered,  "1  hope  it  was  not 
a  case  of  cancer,"  as  happened  to  the  author  on  his  being  at- 
tacked by  blood-poisoning  through  a  prick  received  while 
operating  for  appendicitis. 

All  these  evidences  of  alarm  on  the  part  of  the  public  are 
directly  traceable  to  rash  or  careless  statements,  apparently 
with  a  statistical  foundation,  that  cancer  is  a  pestilential  dis- 
ease, or  that  it  has  been  proved  to  be  infective. 

This  idea  is  carried  much  further  by  la^onen,  with  some  of 
whom  the  notion  is  deeply  rooted  that  cancer  is  allied  to 
syphilis.  The  belief  even  obtains  that  cancer  never  develops 
without  being  preceded  by  syphilis.  Anyone  may  call  to  mind 
noble  individuals  on  whom  no  such  suspicion  could  rest,  and 
the  occurrence  of  cancer  in  animals,  among  whom  syphilis  is 
unknowm,    demonstrates    its   absurdity.      Nevertheless,    an    in- 


STATISTICAL    CONSIDERATIONS  95 

stance  may  be  cited  in  which  a  happy  family,  in  one  of  whose 
members  cancer  appeared,  was  inflicted  with  the  unnecessary 
additional  misery  caused  by  the  assertion  of  a  college-trained 
girl  to  the  effect  that  in  all  cases  of  cancer,  syphilis  must  have 
preceded  its  appearance.  The  effect  of  such  indirect  imputa- 
tions of  immorality  is  disastrous.  They  are  directly  traceable  to 
persons  handling  figures  whose  statistical  significance  or  worth- 
lessness  they  are  unable  to  appreciate.  Especially  is  this 
effect  seen  in  the  desire  to  falsify  death  certificates  of  promi- 
nent or  rich  people,  in  order  to  conceal  the  fact  that  cancer  was 
the  cause  of  death.  Under  pressure  from  the  relatives  many 
deaths  from  cancer  are  doubtless  returned  as  from  some  other 
cause.  Even  among  the  poor,  especially  in  America,  cancer  is 
considered  as  loathsome  a  disease  as  leprosy,  and  the  dread  of 
having  the  truth  disclosed  often  leads  to  the  refusal,  by  rich  and 
poor  alike,  of  autopsy.  Thus  the  alarm  of  the  public,  arising 
from  statements  claiming  to  have  a  statistical  basis,  but  in  fact 
having  no  such  foundation,  contributes  largely,  in  its  turn,  to 
the  invalidation  of  statistics. 

A  final  illustration  of  another  popular  fallacy,  kept  alive  by 
figures  quoted  by  dietetic  enthusiasts,  may  be  referred  to  in 
this  connection,  namely,  that  Jews,  particularly  orthodox  Jews, 
never  suffer  from  cancer.  The  statement  is  supposed  to  have  a 
statistical  basis,  but  in  reality  has  none  at  all,  such  statistics 
as  are  available  proving  exactly  the  opposite.  The  idea  origi- 
nated, no  doubt,  in  the  biblical  classification  of  the  pig  as  an 
unclean  animal;  indeed,  those  who  declare  the  exemption  of 
Jews  from  cancer  generally  direct  attention  to  the  consumption 
of  pork  by  Christians.  There  are  more  Jews  in  ISTew  York 
than  there  are  in  all  Germany,  but  there  are  no  statistics  avail- 
able which  would  show  their  relative  liability.  For  Berlin  the 
deaths  are  classified  according  to  religious  confession,  but  un- 
fortunately no  statement  is  made  as  to  the  relative  frequency  of 
causes  of  death  in  the  separate  confessions.  The  author,  how- 
ever, has  had  the  opportunity  of  operating  for  cancer  upon 
many  Jews.  In  one  instance  the  patient,  who  had  sarcoma,  was 
the  young  daughter  of  a  Rabbi,  regarding  whose  orthodoxy 
there  could  be  no  question.  This  case  attracted  considerable 
attention,  showing  how  widely  spread  is  the  belief  that  Jews 
are  exempt. 

Theilhaber  ^  has  published  figures  from  his  clinic  in  Munich 

1  Theilhaber,  F. — ' '  Zur  Lehre  von  dem  Zusammenhang  der  Sozialen 
Stellung  und  der  Rasse  mit  der  Entstehung  der  Uteruscarcinome, ' '  Zeitsch. 
f.  Krebsforschung,  Bd.  VIII,  1909,  p.  466. 


Q6  THE    CANCER    PROBLEM 

recording  some  cases  in  Jews.  Sir  Frederic  Eve  *  has  pro- 
vided figures  of  the  operations  for  cancer  on  Jews  in  the  T^on- 
don  Hospital,  where  provisions  are  made  for  orthodox  and 
unorthodox  Jews,  there  being  actually  a  "Kosher"  kitchen  in 
that  institution.  Finally  the  attempt  has  been  made  to  show 
that  cancer  is  less  frequent  in  Jews  than  in  Christians  in 
Amsterdam;  but  the  figures,  while  demonstrating  that  cancer 
is  by  no  means  uncommon  among  the  Jews  of  that  city,  are  too 
small  to  permit  of  a  comparison,  nor  has  any  attempt  been 
made  to  separate  the  orthodox  from  the  unorthodox,  by  which 
means  alone  the  effect  of  diet  and  alcohol  could  be  determined 
by  the  comparison  of  these  cases  with  those  of  Christians. 

The  following  tables,  compiled  by  the  author  from  the  records 
of  the  London  Hospital  in  the  summer  of  1913,  is  interesting 
in  this  connection.  Unfortunately  the  ages  of  the  patients 
had  not  been  obtained,  and  it  is  impossible  to  say  to  what  ex- 
tent this  factor  modifies  the  relative  frequency  of  cancer  in 
Jews  and  Gentiles  in  this  hospital. 

Hereditary  influence  is  another  problem  that  statistics  have 
been  called  upon  to  solve.  Every  surgeon  knows  of  cases  in 
which,  after  operating  on  the  mother,  a  lapse  of  years  has 
found  him  performing  the  same  service  for  the  daughter,  or  for 
some  other  near  relative.  Many  would  be  satisfied  with  these 
facts  as  evidence  of  the  influence  of  heredity.  This  conclusion 
by  no  means  necessarily  follows. 

Percentages  of  Carcinoma  Cases  Admitted  to  London  Hospital  in  the  Year  1911. 

Males: 

Total  admission 5,658 

Gentiles 5,444 

Jews 214 

Among  the  5,444  Gentiles  there  were  278  carcinoma  cases,  or  5.1  per  cent. 

Among  the  214  Jews  there  were  7  cases  of  carcinoma,  or  3.3  per  cent. 

Females: 

Total  admission 3,681 

Gentiles 3,408 

Jews 173 

Among  the  3,408  Gentiles  there  were  212  carcinoma  cases,  or  6.2  per  cent. 

Among  the  173  Jews  there  were  11  cases  of  carcinoma,  or  6.4  per  cent. 

Females  Admitted  under  Gynecological  Department: 

Total  admission 803 

Gentiles 699 

Jews 104 

Among  the  699  Gentiles  there  were  60  cases  of  carcinoma,  or  8.6  per  cent. 

Among  the  104  Jews  there  were  3  cases  of  carcinoma,  or  2.9  per  cent. 

*  Eve,  Sir  Frederic. — Personal   communication. 


STATISTICAL    CONSIDERATIONS 


97 


Detail  Report  of  Total  Number  of  Carcinoma  Cases,  Together  with   Columns 
Showing  Number  of  Jews  in  Each  Group. 


Gentiles 

Jewb 

Site 

Malea 

Females 

Males 

Femalea 

A  =  Abdominal. 

Appendix 

0 
30 

4 

5 
39 
31 

5 

1 

28 

6 

8 

19 

21 

3 

Colon 

1 

Pancreas , 

1 
1 

0 

Peritoneum 

0 

Rectum  and  Anus 

2 

Stomach 

4 

0 

Various 

1 

Total 

114 

86 

6 

4 

Total  males,  Jews  and  Gentiles . 
Total  Females,  Jews  and  G 'tiles 

120 
90 

fi  =  Geni to-urinary  System. 

Bladder  and  Kidney 

Penis,  Prostate,  Scrotum,  and 
Testicle 

16 
21 

9 

0 
0 

1 

Ovary,  Uterus,  and  Vagina .  . 

8 

0 

Total 

37 

17 

0 

1 

C  =  Upper  Alimentary  Tract. 

Lip  

19 
18 
28 
34 
10 

1 

1 
2 
4 

1 
0 
0 
0 
0 

0 

Mouth  and  Cheek 

0 

Tongue 

0 

(Esophagus 

1 

Various 

0 

Total 

109 

8 

1 

1 

Z)  =  Breast. 

Breast 

1 

90 

0 

5 

£=  Various. 

Various 

17 

11 

0 

0 

Totals. 

A 

114 
37 

109 

1 

17 

86 
17 
8 
90 
11 

6 
0 

1 
0 
0 

4 

B 

1 

C 

1 

D 

5 

E 

0 

278 

212 

7 

11 

All  the  difficulties  raised  by  the  great  average  frequency, 
when  using  associated  cases  as  evidence  of  infection,  arise 
here  again  even  in  an  enhanced  degree.     Pedigrees  constructed 


98  THE    CANCER    PROBLEM 

for  many  generations  awake  mistrust,  owing  to  the  greater 
uncertainty  of  the  canse  of  death  as  given  one  hundred,  or  even 
fifty,  years  ago,  and  because  it  is  not  granted  to  us  personally 
to  observe  completely  more  than  one  generation  of  the  human 
race. 

Hence  directly  contradictory  views  have  been  held  in  the 
l)ast  by  equally  competent  authorities.  Sir  James  Paget  ^ 
believed  that  heredity  was  responsible  in  as  many  as  26  out  of 
160  cases,  or  one-sixth,  and  was  ''disposed  to  hold  that  it  is  not 
possible  to  conceive  the  origin  of  cancer,  or  of  any  disease  of 


31   months 

over  2"4 

Fig.  6. — Percentage  of  deaths  from  mammary  carcinoma  to  deaths  from  all 
causes  at  successive  3-monthly  age-periods  in  female  mice  of  recently 

cancerous  ancestry  (mother,  grandmothers)  ,  compared  with  the 

same  ratio   in  female  mice   having   more   remote   cancerous   ancestry 
(mother  and  grandmothers  non-cancerous) . 

the  kind,  except  by  inheritance."  ^  Roger  Williams  ^  and  Sir 
Henry  Butlin  ^  have  more  recently  claimed  importance  for  it, 
but  equally   recently  Bashford  ^    and  Weinberg  ^   have   given 

1  Paget,  Sir  James. — ' '  Lectures  on  Clinical  Pathology, ' '  Vol.  II,  London, 

loOO. 

2  Quoted  by  Harrison  Cripps. — ' '  Cancer  of  the  Eectum, ' '  London,  1880. 
^Williams,  Roger.— "The  Natural  History  of  Cancer,"  N.  Y.,  1908. 

*  Butlin,  Sir  Henry  T. — ' '  Discussion  on  the  Influence  of  Heredity  on 
Disease,"  Proc.  Roy.  Soe.  of  Med.,  London,  November,  1908,  Vol.  2, 
R.S.M.,  p.  75. 

=  Bashford,  E.  F.— "Heredity  and  Cancer,"  Proc.  Roy.  Soc.  of  Med., 
London,   November,  1908,  Vol.  2,  R.S.M.,  p.  63. 

'Weinberg,  W.  and  Gastpar. — Bosartige  Neubildungen  in  Stuttgart," 
Zeitsch.  f.  Krebsforschung,  Bd.  II,  1904,  p.  195. 


STATISTICAL    CONSIDERATIONS 


99 


elaborate  figuros  from  which  they  were  unable  to  deduce  proof 
of  its  influence  for  the  human  subject. 

These  statistical  difficulties  led  to  a  resort  to  experiment, 
and  finally  experiments,  interpreted  by  the  aid  of  statistics, 
have  demonstrated,  in  the  case  of  mice,  that  an  hereditary  in- 
fluence does  obtain.  Hence  the  lengthy  disputations  on  this 
subject  may  be  passed  over. 

Mice   of  Recent  Cancerous  /incestry. 

. -        «   Remote      -         »  »         .  .(Mother  and 

both  grandmothers   non -cancerous^ 


24  Months. 


J8-I-09  to  /7/0-/2 (inc/uslye).  Lilies  at  risk  at  ages  more 
than  six  months,    c/uring    /5  censUs-u/eeks    chosen  at 
interya/s    of  t/iree   months,   in  the  period    under  reviei^. 

Fig.  7.— Curves  showing  the  death-rate  from  cancer.  Stated  in  this  way 
the  figures  correspond  to  human  mortality  statistics.  There  is  still  a 
higher  incidence  in  mice  of  cancerous  ancestry.  (After  Murray,  Proc. 
of  International  Medical  Congress,  London,  1913.) 


For  some  years  experiments  on  inbreeding  cancerous  mice 
led  to  negative  results,  but  ultimately  Murray  ^  was  able  to  ob- 
tain positive  findings,  and  to  confirm  these  by  prolonging  the 
experiments  over  many  years.  Murray's  findings  are  briefly 
set  forth  in  the  following  tables,  for  which  also  the  accompany- 
ing curves  (Figs.  6  and  7)  have  been  constructed,  one  of  them 
giving  the  latest  results. 

^  Murray,  J.  H. — ' '  Cancerous  Ancestry  and  the  Incidence  of  Cancer  in 
Mice, ' '  Fourth  Scientific  Report  of  the  Imperial  Cancer  Research  Fimd, 
London,  1911,  p.  114. 


100 


THE    CANCER    PROBLEM 


Table  I.  (24th  October,  1910).  Female  Mice  of  recent  cancerous  Ancestry.  (Mother,, 
one  or  both  grandmothers,  or  all  three  cancerous.) 


0-3 

-0 

-9 

-12 

-15 

-18 

-21 

-24 

Over 
24 

To- 
tal 

No  tumour. 

Living 

9 
49 

7 
48 

1 
7 

6 
39 

2 
15 

8 
28 

2 
18 

7 
22 

1 
10 

4 

20 
"5 

6 
18 

1 

3 

47 

Dead 

224 

Tumour  Mice» 

Organs     other     than 
manuna 

7 

Mamma 

4 

6^ 

Total 

62 

63 

62 

56 

40 

29 

28 

340 

Per  cent 

6.5 

11.1 

24.2 

32.1 

25.0 

17.2 

10.7 

18  ? 

Table  II.   (24th  October,  1910).     Female  Mice  of   remote 
(No  cancer  in  mother  or  grandmothers.] 

cancerous 

Ancestry^ 

0-3 

-6 

-9 

-12 

-15 

-18 

-21 

-24 

Over 
24 

To- 
tal 

No  tumour. 

Living 

7 
30 

'37' 

1 

24 

2 

28 

9 
19 

1 
0 

5 

17 

1 
3 

15 
6 

2 
2 

3<» 

Dead 

161 

Tumour  Mice. 

Organs     other     than 
mamma 

4 

Mamma 

1 

4 

1 

8 

19 

Total 

38 

41 

26 

38 

29 

26 

25 

223 

Per  cent 

2.6 

9.8 

3.8 

21.6 

0.0 

11.5 

8.0 

8  6 

■" 

These  breeding  experiments  show  distinctly  that  in  the  case 
of  mice  the  occurrence  of  cancer  of  the  mamma  in  the  mother 
or  grandmothers  increases  the  frequency  of  cancer  of  that 
organ  by  ahnost  10  to  15  per  cent,  at  certain  age-periods,  espe- 
cially the  earlier  age-periods.  Equally  accurate  knowledge  is 
not  obtainable  for  the  human  subject  owing  to  the  greater 
length  of  life  and  the  impracticability  of  always  obtaining 
an  autopsy  and  a  histological  examination.  In  the  light  of  the 
results  of  these  experiments  the  question  arises  as  to  the  im- 
portance attaching  to  those  rare  family  histories  with  an  ex- 
ceptionally high  incidence  of  cancer.  Family  histories  like 
the  following  are  certainly  very  remarkable :  ^'A  man,  one  of 
a  family  of  nine,  died  of  cancer  of  the  liver,  the  others  being 
all  alive  and  well.  The  patient's  mother  was  one  of  a  family 
of  thirteen,  seven  of  whom   (four  males  and  three  females) 


STATISTICAL    CONSIDERATIONS  101 

died  of  cancer.  Two  died  of  cancer  of  the  bladder,  two  of  can- 
cer of  the  liver,  and  one  each  of  cancer  of  the  throat,  uterus, 
and  breast.  The  patient's  father  died  of  diabetes,  but  his  sister 
(the  patient's  paternal  aunt)  died  of  cancer  of  the  bowel. 
Again,  five  members  (four  males  and  one  female)  of  a  family 
of  nine  children  died  of  cancer.  The  four  males  died  of  ab- 
dominal growths  and  the  female  of  cancer  of  the  uterus.  The 
mother  and  mother's  brother  also  died  of  cancer;  the  father 
died  of  phthisis.  The  son  of  the  eighth  son  died  at  the  age  of 
28  of  cancer  of  the  boweh" 

To  these  histories  Bashford  ^  added  the  following  comment 
at  a  time  when  the  breeding  experiments  in  his  laboratory 
were  still  yielding  negative  results:  "Family  histories  of  this 
kind  are,  however,  rare,  in  proportion  to  the  number  of  indi- 
viduals attacked,  and  they  are  mainly  of  interest  as  showing 
that  if  cancer  be  transmissible  by  heredity,  then  transmission 
takes  place  both  through  the  male  and  the  female,  without  any- 
thing corresponding  to  what  is  known  for  haemophilia  and  col- 
our-blindness. These  histories  are  so  infrequent  that  they  cause 
no  surprise  when  the  table  of  the  relative  frequency  of  cancer  in 
the  general  population  given  above  is  considered ;  for,  did  these 
forms  of  family  history  imply  hereditary  transmission,  then 
w^e  should  be  able  with  ease  to  obtain  tables  of  a  hundred  fam- 
ilies in  which  the  figures  for  no  deaths,  one,  two,  three,  or 
more  were  the  inverse  of  what  they  are  in  the  population ;  but 
this  is  not  the  case.  The  isolated  instances  recorded  in  the  lit- 
erature serve  only  to  show  how  rare  this  phenomenon  really  is. 
When  recorded,  it  is  more  than  probably  to  be  looked  upon  as 
what  would  be  expected  to  happen  in  the  case  of  so  frequent  a 
cause  of  death  as  cancer,  from  a  consideration  of  the  distribu- 
tion theoretically  calculated  according  to  the  law  of  probabili- 
ties." 

Raymond  Johnson  and  Lawrence^  give  the  following  recent 
experience :  "Among  500  consecutive  cases  of  carcinoma  of 
the  breast  treated  in  University  College  Hospital,  there  was  a 
family  history  of  malignant  disease  in  81,  and  in  37  of  the  81 
cases  the  disease  was  stated  to  have  been  in  the  breast.  In  one 
of  this  series  of  cases  the  patient's  mother  and  her  sister  died 
from  cancer  of  the  breast,  and  the  father's  sister  from  cancer 
of  the  mouth ;  of  the  patient's  sisters,  2  died  from  cancer,  1  of 
the  stomach  and  1  of  the  breast.  If  heredity  plays  any  impor- 
tant part  in  the  causation  of  the  disease,  it  might  be  expected 

1  Bashford,  E.  F. — ' '  Heredity  and  Cancer, ' '  loc.  cit. 

^  Johnson,  Eaymond,  and  Lawrence,  F.  W.  P. — Article  on  Tumors,  in 
"A  System  of  Surgery,"  edited  by  C,  C.  Choyce,  Vol.  I,  p.  470. 


102  THE    CANCER    PROBLEM 

that  it  would  lead  to  its  incidence  before  the  average  age.  In 
this  connection  it  may  be  stated  that  among  the  500  cases  of 
cancer  of  the  breast  referred  to  above,  the  average  age  at  which 
the  disease  was  first  noticed  M'as  40. (J2  years,  whereas  among 
the  81  cases  in  which  any  evidence  of  heredity  could  be  traced, 
the  averaffc  ac'e  was  48.7-i  vears.  The  difference  in  this  series 
of  cases  is  so  small  as  to  be  negligible,  but  individual  cases  of 
carcinoma  occurring  at  an  unusually  early  age  are  sometimes 
met  with,  as  in  one  of  the  families  mentioned  above,  in  which 
the  probable  effect  of  heredity  cannot  be  disregarded." 

It  seems,  therefore,  that  the  evidence  both  for  the  human 
subject  and  for  breeding  experiments  on  mice,  points  in  the 
same  direction.  Heredity  does  have  a  slight  influence,  and 
occasionally  may  exercise  a  quite  appreciable  influence.  Bash- 
ford  and  Murray,^  however,  issue  an  emphatic  warning  against 
alarm,  by  writing:  "To  guard  against  pessimistic  conclusions  it 
is  well  to  point  out  that  the  influence  of  heredity  has  only  been 
demonstrated  by  studying  stocks  in  which  this  factor  has  been 
concentrated  by  careful  mating,  and  that  the  influence  is 
mainly  exerted  in  the  immediate  descendants.  Such  a  concen- 
tration as  can  be  attained  in  experimental  animals  can  only 
occur  in  the  human  subject  by  hazard,  as  a  coincidence  of 
considerable  rarity,  and  it  is  probable  that  the  influence  of 
heredity  in  the  general  population  is  manifested  as  an  average 
predisposition  of  low  general  intensity." 

It  is  apparent  that  there  are  many  difficulties  in  obtaining 
the  facts  upon  which  to  base  statistics  of  cancer,  and  that  these 
difficulties  are  not  all  capable  of  being  completely  overcome 
even  under  the  most  favorable  circumstances.  The  difficulties 
are  greater  in  the  country  than  in  the  towns,  even  in  coun- 
tries with  the  best  developed  statistics;  they  are  still 
greater  in  the  United  States  in  general,  owing  to  the  vast 
distances,  the  numerous  breaches  of  the  registration  laws,  and 
the  difficulty  of  obtaining  correct  records  in  small,  isolated 
places.  The  immigration  of  from  900,000  to  1,000,000  persons 
annually,  the  floating  character  of  this  annual  additional  popu- 
lation, and  of  much  else  besides,  greatly  augment  the  diffi- 
culties of  properly  accounting  for  age  and  sex  distribution. 
Moreover,  the  great  inequalities  in  the  education  of  those  prac- 
tising medicine  in  the  United  States  militates  against  a  general 
leveling  up  of  the  accuracy  of  the  certification  of  causes  of 
death.  The  falsification  of  the  causes  of  death,  in  consequence 
of  the  physician's  heeding  the  demand  of  the  patient's  family 

1  Introduction  to  the  Tourth  Scientific  Eeport  of  the  Imperial  Cancer 
Research  Fund,  London,   1911. 


STATISTICAL    CONSIDERATIONS  108 

that  the  return  of  the  record  of  death  shall  not  say  cancer,  is 
capable  of  being  overcome  to  a  large  extent  by  making  the 
record  confidential  and  the  intentional  falsification  of  the  death 
return  a  criminal  oftence  both  on  the  part  of  the  doctor  and 
on  that  of  the  persons  instigating  it.  If  the  statistics  of  mor- 
tality are  not  to  defraud  the  public  which  pays  for  such  reports 
on  the  state  bill  of  health,  it  is  as  essential  to  guard  against  the 
wilful  suppression  of  a  cause  of  death  as  it  is  to  prevent  the 
suppression  of  a  birth,  or  the  misstatement  of  the  cause  of  a 
death  really  due  to  an  illegal  operation. 

The  difficulty  of  obtaining  autopsies  may  be  overcome  by 
law,  but  is  more  likely  to  be  overcome  by  educating  the  public 
concerning  the  value  and  harmlessness  of  the  proceeding,  and 
the  fact  that  it  is  in  their  own  interest.  Autopsy  is  often  re- 
fused, especially  among  some  members  of  the  Church  of  Rome, 
not  from  any  doctrine  of  the  Roman  Catholic  faith,  but  because 
many  adherents  of  this  church  celebrate  "wakes"  over  the  dead 
body.  For  other  reasons  the  poor  hold  to  the  sacredness  of 
the  dead  body.  For  example,  among  certain  foreigners  in  the 
lower  parts  of  ISTew  York  it  is  customary  for  the  funeral  cortege 
to  proceed  around  the  block  before  going  to  the  cemetery,  and 
thus  to  pass  the  tenement  in  which  the  deceased  person  had 
lived.  Whether  this  custom  be  followed  "for  luck,"  for  the 
deceased  to  have  one  last  look,  as  it  were,  at  the  former  place 
of  abode,  or  out  of  respect  to  the  dwelling  place,  it  defeats  the 
ends  of  science  in  many  instances  in  which,  otherwise,  autopsy 
would  be  permitted,  and  in  so  far  militates  against  the  statisti- 
cal study  of  the  causes  of  death.  All  such  practices  and  preju- 
dices can  be  overcome  only  by  education,  just  as  objections  to 
anatomical  study  have  been  overcome. 

The  greatest  efforts  are  made  to  obtain  accuracy  of  mor- 
tality statistics  in  England.  For  many  years,  whenever  a 
death  has  been  certified  vaguely,  the  doctor  has  been  written 
to,  and  exact  information  obtained.  In  this  way,  in  1911 
alone,  out  of  12,563  such  inquiries  made,  10,718  replies  were 
received.  The  data  of  the  population,  the  numbers  of  the  two 
sexes,  the  numbers  living  at  each  quinquennial  age-group,  and 
in  town  and  country,  are  therefore  ascertained  with  a  fair 
approach  to  accuracy,  although  little  account  can  be  taken  of 
the  effect  of  emigration.  Moreover,  the  deaths  occurring  in 
institutions  are  known  and  are  transferred  to  the  place  of  abode. 
As  regards  cancer,  the  individual  sites  are  tabulated  and  a 
vague  statement  of  death  from  cancer  is  inquired  into  and  the 
site  or  organ  ascertained.  In  this  way,  although  the  ideal  has 
by  no  means  been  attained  in  that  country,  the  statistics  of 


104  THE    CANCER    PROBLEM 

death  can  have  a  larger  numher  of  "corrections"  applied  to 
them  than  anj-where  else. 

SUMMARY 

The  statistical  study  of  cancer  is  valuable  in  many  direc- 
tions, both  negative  and  positive — in  other  words,  by  what  it 
proves  cancer  is  not,  as  well  as  by  what  it  proves  cancer  is.  It 
has  brought  out  marked  differences  between  cancer  and  the 
epidemic  or  filth  diseases ;  it  has  shown  that  all  races  and 
creeds  are  liable  to  the  disease,  irrespective  of  diet,  soil,  or 
climate,  although  the  question  of  relative  liability  of  different 
parts  of  the  world  and  of  different  races  has  not  been  settled. 

It  has  revealed  the  importance  of  chronic  irritation  by  dem- 
onstrating how  the  distribution  of  cancer  in  the  body  may  be 
altered  by  peculiar  practices  pertaining  to  native  customs  or 
occupations. 

Statistics  have  revealed  the  relation  between  cancer  and  age 
— that  it  is  rare  under  35,  but  frequent  after  middle  life — and 
that  the  relation  of  age  ("age-incidence")  differs  for  different 
organs,  but  is  the  same  for  the  same  organ  in  the  two  sexes. 

Women  suffer  more  from  cancer  solely  because  of  the  lia- 
bility of  the  mamma  and  uterus  to  the  disease.  If  these  organs 
are  deducted,  the  stomach  and  intestines  are  most  liable  in  both 
sexes,  although  the  male  is  more  prone  to  attack,  the  indica- 
tions being  that  alcohol  and  other  irritants  may  determine  his 
greater  liability. 

There  has  been  a  great  increase  in  the  total  number  of  deaths 
recorded  from  cancer,  partly  due  to  improved  certification  of 
causes  of  death  and  improved  diagnosis,  and  also  because  more 
people  nowadays  attain  to  ripe  years.  This  must  not  be  con- 
founded with  the  question  of  a  relative  increase.  When  the 
figures  are  analyzed  it  is  shown  that  there  has  been  no  relative 
increase  for  some  parts  of  the  body,  for  example,  skin,  uterus, 
ovary,  liver,  but  that  for  other  sites,  notably  stomach  and  in- 
testines, breast  and  tongue,  there  has  been  a  relative  increase. 
The  question  whether  this  relative  increase  is  real  or  only  ap- 
parent has  not  yet  been  decided.  There  is  some  probability  that 
a  good  deal  of  the  increase  for  the  stomach  and  intestines  may 
be  explained  by  improved  diagnosis  and  certification  of  causes 
of  death,  owing  to  the  improved  methods  of  surgical  diagnosis, 
but  for  the  tongue  and  breast  this  would  hardly  hold.  In  the 
case  of  the  breast,  the  increase  in  the  inability  of  women  to 
suckle  their  children  calls  for  investigation. 


STATISTICAL    CONSIDERATIONS  105 

Heredity  has  been  shown  to  play  a  role,  but  not  one  to  cause 
anxiety. 

Finally,  statistics  have  disposed  of  some  popular  fallacies 
regarding  "cancer  houses"  and  the  risks  of  infection  so  widely 
feared. 


SECTION    IV 

ETIOLOGY 

CHAPTER   I 
THEORIES 

EARLY    THEORIES 

Despite  the  seeming  absurdity  of  such  theories,  Hippocrates, 
Celsus,  and  Galen  conceived  that  there  were  four  cardinal 
fluids  in  the  body — blood,  mucus,  yellow  bile,  and  black  bile. 
An  excessive  accumulation  of  black  bile  was  thought  to  be  the 
cause  of  cancer,  which  term,  for  them,  covered  not  only  such 
of  the  true  carcinomata  and  sarcomata  as  they  had  recognized, 
but  much  else  besides.  Their  classification  went  little  further 
than  distinguishing  malignant  ulcers  from  malignant  tumors, 
cancer  apertus  from  cancer  occlusus. 

Early  anatomists,  like  Vesalius,  Fallopius,  and  Leonardo  da 
Vinci,  did  much  to  break  away  from  the  domination  of  the 
humoral  theories,  which  had  held  for  centuries.  Paracelsus 
made  a  further  advance;  and  the  treatment  adopted  by  the 
famous  surgeon,  Ambroise  Pare,  shows  that,  like  his  predeces- 
sor, Leonidas,  he  had  emancipated  himself  from  the  doctrine 
of  Hippocrates,  never  to  operate  on  an  "open"  cancer. 

But,  even  at  the  end  of  the  eighteenth  century,  famous  an- 
atomists, like  John  Hunter  and  Alexander  Munro,  still  re- 
mained under  the  influence  of  the  old  humoral  theories  as  modi- 
fied by  Descartes.  The  discharge  of  ulcerating  cancer  came  to 
be  widely  designated  as  the  "cancerous  virus,"  and  was  regarded 
as  its  chief  characteristic;  so  much  so  indeed,  that,  in  1773,  a 
prize  was  awarded  to  the  author  of  a  famous  book  (Peyrilhe), 
describing  how  sloughing  had  been  produced  in  a  dog  by  sub- 
cutaneous injection  of  a  discharge  obtained  from  a  man. 

Walshe,^  writing  in  1846,  said  with  reference  to  the  various 

1  Walshe,  Walter  Hayle. — ' '  The  Nature  and  Treatment  of  Cancer, ' ' 
London,  1846,  p.  35. 

106 


ETIOLOGY— THEORIES  107 

theories  of  the  origin  of  "cancerous  substance" :  "The  majority 
of  these  are  either  so  prima  facie  absurd,  so  insignificant,  or  so 
repugnant  to  the  results  of  sound  observation,  that  they  are  only 
fitted  to  figure  among  the  curiosities  of  medical  literature.  The 
reader  may  well  be  spared  an  inquiry  into  speculations  ascrib- 
ing cancer  to  atrabilis  or  a  melancholic  humor — to  lymph  con- 
verted into  an  acrid  and  destructive  fluid — to  the  presence  of 
a  gas  possessing  properties  analogous  to  those  of  hydro-sulphuric 
acid — to  fluids  spontaneously  effused  and  rendered  corrosive 
by  putrefaction — to  the  depravation  of  the  nervous  fluid — or  to 
the  presence  and  action  of  a  virus  composed  of  an  ammoniacal 
fluid  containing  oxide  of  nitrogen  in  excess." 

"With  these  vain  hypotheses,"  quoting  further  from  Walshe, 
"may  assuredly  be  classed  that  which,  under  different  forms, 
seeks  to  connect  the  appearance  of  cancer  with  the  presence 
and  agency  of  parasitic  animals.  I  should  indeed,"  he  con- 
tinues, "scarcely  have  conceived  it  necessary  to  advert  more 
particularly  to  this  theory  than  to  the  others,  just  mentioned, 
had  it  not  been  very  recently  revived  with  considerable  pre- 
tension. It  appears  to  have  first  attracted  attention  through 
the  writings  of  Justamond,^  an  author  of  the  last  century,  who 
ascribed  the  formation  of  cancer  to  'insects,  or  the  germina  of 
these,  taken  up  from  the  air  by  the  lymphatic  vessels.'  He 
quotes  a  thesis  by  Martin  Schumacher,  and  the  work  of  Qua- 
drio,^  to  show  that  he  was  by  no  means  singular  in  entertaining 
this  opinion.  The  latter  writer  had  seen  the  insect,  and  de- 
scribed its  length,  breadth,  and  colour." 

I  have  reverted  to  the  opinion  of  Walshe,  who  was  a  dis- 
tinguished member  of  the  medical  profession  of  his  day,  a 
careful  observer,  and  a  fluent  writer,  to  show  how,  so  far  as 
the  etiology  of  cancer  is  concerned,  the  past  is  linked  with  the 
present.  The  last  influence  of  the  old  humoral  conception  of 
cancer  did  not  disappear  until  the  time  of  Virchow,  or  about 
the  middle  of  the  last  century.  The  influence  of  the  theories 
of  the  parasitic  origin  of  the  disease  may  be  said  to  continue 
to  be  felt  down  to  the  present  moment.  Those  who  have  fol- 
lowed the  history  of  the  modern  study  of  cancer  have  been 
carried  through  a  succession  of  hypotheses  as  to  the  causative 
influence  of  protozoa,  entozoa,  and  various  vegetable  and  animal 
parasites,  some  of  which  still  figure  in  cancer  literature. 

1  Justamond,  J.  O. — ' '  An  Account  of  the  Methods  Pursued  in  the  Treat- 
ment of  Cancerous  and  Scirrhous  Disorders  and  Other  Indurations,"  1870, 
p.  65. 

^  Quadrio,  Giuseppe  Maria. — ' '  Nuvo  metodo  por  curare  ogni  eanehero 
eoperto  e  specialmente  le  ghiande  scirrhose  delle  mamelle,  e  di  altre  porti 
del  corpo, "  Venezia,  1750. 


108  THE    CANCER    PROBLEM 

THEORIES   WHICH   HAVE    ENGAGED    ATTENTION 

SINCE   THE   BEGINNING   OF  MODERN 

CANCER   RESEARCH 


BIOLOGICAL   THEORIES 

Influence  of  Humoral  Theory  upon  the  Scientific  Study  of  Can- 
cer.— Virchow,  while  forever  liberating  pathology  as  we  know 
it  to-daj  from  the  incubus  of  the  humoral  conceptions  of  dis- 
ease, had  not  entirely  rid  himself  of  their  influence  when  he 
considered  tumors  and  cancer  as  crystallizing  out  of  a  universal 
connective  tissue  matrix.  He  showed  his  common  sense,  how- 
ever, by  not  continuing  his  Onkologie  ^  after  the  publication 
of  the  investigations  of  Thiersch  ^  and  Waldeyer,^  whose  dem- 
onstrations as  to  the  histogenesis  of  cancer  from  corresponding 
tissues,  entirely  upset  his  ideas. 

Yet  how  tenaciously  the  old  humoral  ideas  of  disease  con- 
tinued their  hold  upon  the  medical  mind,  and  how  widely  they 
separate  the  standpoint  of  forty  years  ago  from  that  of  to-day, 
may  be  illustrated  by  the  writings  of  the  distinguished  English 
surgeon  and  pathologist.  Sir  James  Paget.*  That  he  was  fa- 
miliar with  the  work  of  Virchow  is  evident  from  frequent 
references  in  his  "Lectures  on  Surgical  Pathology,"  published 
in  1853.  Yet  in  1874,  in  a  debate  at  the  Pathological  Society 
of  London,  he  still  defended  the  views  he  had  set  forth  in  1853 
as  to  the  humoral  origin  of  cancer.  As  it  is  most  important  in 
the  interest  of  medical  education,  alike  of  the  profession  itself, 
and  of  the  laity,  that  there  should  be  no  misunderstanding  as 
to  what  was  known  or  debatable  forty  or  fifty  years  ago,  and 
what  is  no  longer  even  debatable  to-day,  it  seems  advisable  to 
give  the  following  quotation  from  Paget's  famous  book.  Writ- 
ing of  cancerous  growths,  he  held  that  "They  are  local  mani- 
festations of  certain  specific  morbid  states  of  the  blood;  and 
that  in  them  are  incorporated  peculiar  morbid  materials  which 
accumulate  in  the  blood,  and  which  their  growth  may  tend  to 
increase." 

"In  the  terms  which  are  more  usual  in  discussions  respecting 
the  nature  of  cancers,  I  would  say  that  a  cancer  is,  from  the 
first,  both  a  constitutional  and  a  specific  disease.     I  believe  it 

1  Virchow,  Rudolph.— "  Die  Krankhafte  Geschwiilste, "  1863-65. 

'  Thiersch,  Carl. — *  *  Der  Epithelialkreba,  namentlich  der  Haut, ' '  Leipzig, 
1865. 

'Waldeyer,  W. — "Die  Entwicklung  der  Carcinome, "  Virchow 's  Archiv, 
Vol.  41,  1867,  p.  470.     Ihid.,  Vol.  55,  1872,  p.  67. 

3  Paget,  Sir  James. — ' '  Lectures  on  Surgical  I'athology, ' '  London,   1853. 


ETIOLOGY— THEORIES  10<> 

to  be  constitutional,  in  the  sense  of  having  its  origin  and  chief 
support  in  the  blood,  by  which  the  constitution  of  the  whole 
body  is  maintained;  and  I  believe  it  to  be  specific,  first,  in  the 
sense  of  its  being  dependent  on  some  specific  material,  which  is 
different  from  all  the  natural  constituents  of  the  body,  and 
difi^erent  from  all  the  materials  formed  in  other  processes  of 
disease;  and,  secondly,  in  the  sense  of  its  presenting,  in  a  large 
majority  of  cases,  structures  which  are  specific  or  peculiar  both 
in  their  form  and  in  their  mode  of  life. 

''The  evidences  of  this  hypothesis  appear  in  the  conformity 
of  cancer  to  the  other  specific  diseases,  for  which  a  similar 
hypothesis  is  nearly  proved,  and  in  the  fitness  of  the  terms 
which  it  supplies  for  the  general  pathology  of  cancer." 

"The  general  history  of  cancers,"  he  continues,  ''and  their 
analogy  with  other  diseases  that  are,  in  the  same  senses,  specific 
and  constitutional,  imply  that,  before  the  formation  of  a  can- 
cerous growth,  two  things  at  least  must  co-exist;  namely,  a 
certain  morbid  material  in  the  blood,  and  some  part  appropriate 
to  be  the  seat  of  a  grovrth  incorporating  that  material,  some 
place  in  which  the  morbid  material  may  assume,  or  enter  into, 
organic  structure. 

"The  existence  of  the  morbid  material  in  the  blood,  whether 
in  the  rudimental  or  in  the  effective  state,  constitutes  the  gen- 
eral predisposition  to  cancer ;  it  is  that  which  is,  by  some,  called 
the  predisposing  cause  of  cancer.  The  morbid  material  is  the 
essential  constituent  of  the  'cancerous  diathesis,  or  constitu- 
tion' :  and  when  its  existence  produces  some  manifest  impair- 
ment of  the  general  health,  independently  of  the  cancerous 
growth,  it  makes  the  'primary  cancerous  cachexia.' 

"That  which  evidently  makes  some  part  of  the  body  appro- 
priate for  the  growth  of  a  cancerous  tumour  is  a  so-called  excit- 
ing cause  of  cancer;  but  it  is  a  cause  of  cancer  only  in  so  far 
as  it  fits  some  part  of  the  local  manifestation  of  a  disease 
which  already,  in  its  essential  material,  exists  in  the  blood. 

"It  seems  very  important  to  keep  constantly  in  view  that 
these  two  conditions  must  coincide  before  the  appearance  of 
a  cancerous  growth ;  important  not  only  to  recognize  their 
existence,  but,  if  we  can,  to  measure  the  several  degrees  in 
which,  in  each  case,  they  are  present ;  because,  upon  our  recog- 
nition of  the  shares  in  which  they  respectively  contribute  to 
the  production  of  the  cancerous  tumour,  must  depend  the  chief 
principles  of  practice  in  relation  to  the  removal  of  such 
tumours.  The  larger  the  share  taken  by  the  constitutional  ele- 
ment of  the  disease, — that  is,  by  the  cancerous  condition  of  the 
blood, — in  the  production  of  a  cancerous  growth,  the  less  is  the 


110  THE    CANCER    PROBLEM 

probability  of  advantage  to  be  derived  from  the  removal  of  that 
growth ;  while,  on  the  other  hand,  the  more  largely  the  local 
state  enters  into  the  conditions  upon  which  the  cancerous  growth 
is  founded,  the  more  benefit  may  we  anticipate  from  the  re- 
moval of  the  cancer  and  of  the  locality  with  it." 

It  is  not  surprising  that  Paget,  holding  such  views,  despaired 
of  the  treatment  of  cancer  by  surgical  removal,  as  did  S^ine, 
Benjamin  Brodie,  and  other  distinguished  surgeons  of  that 
time.  As  shown  in  the  chapter  on  Histopathology  (Section  V, 
jD.  142),  such  theories  were  then  opposed  only  by  IMoore  and  De 
Morgan,  who  were  ahead  of  their  times  in  advocating  views  in 
accordance  with  modern  conceptions  of  the  circumscribed  origin 
of  cancer.  To-day  the  old  pathology  of  Paget  is  paraphrased 
and  set  forth  as  something  new  by  certain  self-styled  "cancer- 
specialists"  w'ho  do  not  scruple  to  use  the  name  of  Paget,  Syme, 
Brodie,  and  others,  to  give  the  appearance  of  authority  to  their 
writings. 

By  1887  the  morbid  condition  in  the  blood  had  become  a 
micro-organism  for  Paget.  He  then  wrote :  ^  "I  think  that 
we  may  justly  hope  to  find  a  remedy  in  the  constant  and  care- 
ful study  of  the  likeness  of  these  diseases  to  others  of  which 
we  already  have  means  of  useful  treatment.  We  may  be  the 
more  hopeful  because  of  the  nearest  likenesses  of  cancer  and 
cancerous  diseases  are  to  two  other  groups  of  diseases,  concern- 
ing w^hich  there  have  been  in  most  recent  times,  very  useful  ad- 
ditions to  our  knowledge.  In  one  direction  we  have  their  like- 
ness to  the  simple  or  innocent  tumours,  in  the  surgical  removal 
of  which  the  risk  of  life  has  been  diminished,  even  while  the 
range  of  operating  has  been  increased ;  and  in  the  other  direc- 
tion we  have  their  likeness,  which  I  believe  to  be  much  more 
intimate,  to  some  of  the  specific  and  micro-parasitic  diseases,  a 
group  in  which  there  has  been  progress  toward  both  preventive 
and  remedial  treatment." 

Paget  developed  his  views  along  the  lines  that  the  dissemina- 
tion of  cancer  was  like  that  of  pyemia  rather  than  what  would 
be  expected  if  transported  cells  gave  rise  to  emboli.  In  1887  he 
still  deplored  the  many  failures  of  surgery,  but  nothing  now 
justifies  quoting  him  as  an  opponent  of  surgery  even  in  those 
days  of  still  unperfected  technic  and  vague  knowledge. 

As  has  been  described  under  structure,  it  is  now  known  that 
cancer  arises  in  a  circumscribed  area,  and  is  derived  from  cells 
preexisting  in  the  part  in  which  it  arises,  whether  these  cells 
be  in  their  normal  situation  or  displaced  because  of  some  ab- 

1  Paget,  Sir  James. — The  Morton  Lecture  on  Cancer  and  Cancerous  Dis- 
eases.    Lancet,  November  19,  1887,  p.  999. 


ETIOLOGY— THEORIES  111 

normality  of  development.  The  problem  of  causation  resolves 
itself  into  explaining  the  progressive  growth  of  cells  derived 
from  corresponding  cells  of  the  organism  itself,  and  behaving, 
anatomically  and  physiologically,  quite  independently  of  it. 

Virchow's  Theory. — Virchow  ^  put  forward  the  first  rational 
theory  of  causation.  As  we  have  already  seen,  his  idea  that 
the  cancer  cells  crystallized  out  of  a  connective  tissue  matrix 
was  shown  to  be  wrong,  but  his  attribution  of  cancer  to  the  ef- 
fects of  chronic  irritation  is  still  widely  held  to  be  correct. 
Virchow  thought  chronic  irritation  produced  a  granulation  tis- 
sue which,  like  early  embryonic  tissue,  was  undifferentiated  in 
appearance,  and  thereupon  differentiation  took  place  in  the 
form  of  the  tumour. 


FERTILISED 


'rri'ri'i'riM'ri'riTn'iTi'i  ri  iTi'i'i'iTri 

aECaODUCTIvE  DlFFERtNTlf>TEO'SOMATI{rTlSSUt  Of  ADULT 

TISSUE 

Fig.  1. — Diagrammatic  representation  of  the  differentiation  of  somatic  and 
reproductive  tissues  in  the  higher  animals,  indicating  the  Umitation  of  the 
amount  of  growth  which  determines  the  size  of  the  body,  and  also  the 
duration  of  life. 


Thiersch's  Theory. — Thiersch,^  benefiting  by  the  advance  of 
embryological  and  histological  study,  was  able  to  derive  carci- 
noma of  the  skin  from  the  skin  itself,  and  sharply  to  differen- 
tiate the  epithelium  from  the  connective  tissue.  He  sought  the 
explanation  in  a  disturbance  of  the  equilibrium  established  be- 
tween epithelium  and  connective  tissue.  According  to  him, 
with  advancing  age  the  connective  tissue  ceased  to  be  able  to 
hold  the  epithelium  in  check,  and  it  therefore  grew  into  the 
former.  The  modern  conceptions  of  development  and  of  the 
relations  between  cancer  cells  and  the  connective  tissue  are 
quite  the  opposite,  viz.,  that  the  epithelium  determines  the 
character  of  the  connective  tissues  during  the  development  of 
the  several  organs,   and  that  the  cancer  cells  mold  the  con- 

1  Virchow,  op.  cit. 
■"  Thiersch,  op.  cit. 


112 


THE    CANCER    PROBLEM 


nective  tissue  to  their  special  requirements.  Thiersch  did  not 
deny  that  chronic  irritation,  inflammation,  or  injury  might  be 
indirect  causative  factors. 

Waldeyer's  Theory. — Waldeyer,*  following  up  Thiersch's 
work,  came  to  the  conclusion  that  all  carcinomata  were  epi- 
thelial growths  derived  from  the  corresponding  epithelium,  and 
that  the  secondary  growths  were  the  offspring  of  transplanted 
cells,  and,  not  a  transformation  of  the  tissue  in  which  they 
occurred.  He  drew  a  sharp  distinction  between  carcinoma  and 
sarcoma,  and  held  that  the  latter  was  likewise  a  connective 


FtRTIUSED 


Pig.  2. — Diagram  of  the  hypothesis  of  Thiersch  and  Waldeyer.  The  earlier 
senihty  of  the  connective  tissues  was  assumed  to  allow  of  renewed,  unUm- 
ited  growth  of  epithehum.  The  cells  were  further  assumed  to  revert  to 
an  embryonic  type  as  represented  in  the  last  row. 


tissue  tumor.  Waldeyer  was  impressed  with  the  great  vascu- 
larity of  early  malignant  new  growths,  and  with  the  accumula- 
tion of  white  blood  corpuscles,  so  that  the  appearances  were 
almost  those  of  inflamed  tissues.  He  asks,  therefore :  ''Is  it  not 
possible  that  the  excessive  nourishment  and  loosening  {'Locke- 
rung')  of  the  connective  tissues  thereby  involved,  assist  in  the 
advance  of  the  epithelial  cells  ?  Is  it  not  possible  that  in  this 
way  local  chronic  inflammatory  processes — especially  those 
arising  from  repeated  irritations  which  cause  circumscribed 
inflammation — may  eventually  pass  over  into  cancerous  de- 
generation ?"  These  questions,  he  held,  deserved  the  most 
1  Waldeyer,  op.  cit. 


ETIOLOGY— THEORIES  113 

earnest  examination,  as  perhaps  from  them  might  be  obtained 
some  valuable  indications  for  the  prophylaxis  of  cancer,  par- 
ticularly as  already  a  number  of  other  experiences,  especially 
those  of  a  clinical  nature,  pointed  to  some  connection  between 
chronic  inflammatory  stimulation  and  cancerous  degeneration. 

Thus  Waldeyer,  while  finally  disposing  of  the  actual  descrip- 
tive basis  of  Virchow's  views,  and  of  those  of  all  his  predeces- 
sors, was  also  able  to  give  a  renewed  lease  of  life  to  the  impor- 
tance which  Virchow  attached  to  chronic  irritation.  It  will  be 
noted  that  Waldeyer  conceived  repeated  irritation  to  be  the 
essential  factor.  He  also  entertained  the  probability  that  an 
entire  organ  was  liable  to  cancer,  and  for  this  reason  advised 
extensive  operation. 

Waldeyer  differed  from  Thiersch  in  holding,  that  not  the 
connective  tissue,  but  the  epithelium,  became  weakened  with 
advancing  years,  and  that  the  greater  or  increased  activity  of 
the  connective  tissue  led  to  the  epithelium  being  isolated  and 
surrounded  with  sclerotic  tissue,  in  consequence  of  which  it 
might  undergo  cancerous  transformation. 

Cohnheim's  Theory. — Cohnheim  ^  elaborated  a  view  originally 
expressed  by  Remak.^  According  to  this  theory,  which  was 
dominant  for  many  years,  cancer  arose  in  persistent  embryonic 
rests  which,  owing  to  their  displacement  from  their  normal 
environment,  had  not  been  incorporated  during  the  normal 
development  of  the  organism,  and  had  not  degenerated.  Thus 
cancer  was  simply  a  renewal  of  embryonic  growth,  the  po- 
tentiality for  which,  in  consequence  of  the  displacement,  had 
been  retained.  The  theory  did  not  explain  why  these  cells 
remained  latent  for  years,  nor  why  only  an  occasional  "cell 
rest"  developed  into  cancer.  Subsidiary  hypotheses  were  called 
in.  Irritation  was  again  called  upon  to  explain  why  latent 
germs  began  to  grow  actively.  The  greater  frequency  of  cancer 
at  the  openings  of  the  body  than  throughout  the  length  of  the 
tubes ;  its  greater  frequency  in  parts  where  congenital  displace- 
ments were  more  common  or  the  processes  of  development  more 
complicated,  were  alleged  as  evidence. 

It  would  take  too  much  space  to  put  forward  all  the  argu- 
ments for  and  against  Cohnlieim's  theory.  It  may  be  stated, 
however,  that  tumors  and  malignant  new  growths  do  arise  at 
times  from  what  are  the  results  of  anomalies  of  development, 
for  example,  teratomata  and  mixed  tumors,     l^evertheless,  the 

*  Cohnheim,  Julius. — Vorlesungen  iiber  allgemeine  Pathologie.  Vols.  1  and 
2,  2nd  ed.,  Berlin,  1882. 

2Kemak,  Robert.— "  Ueber  die  Entwicklung  der  Gesehwiilste, "  Deutsche 
Klinik,  1854,  No.  19. 


114 


THE    CANCER    PROBLEM 


superposition  of  malignant  new  growths  upon  the  growth  of 
embryonic  tissue  is  to-day  regarded  as  being  just  as  much  a 
problem  for  solution  as  is  its  acquirement  by  tissue  still  growing 
in  normal  continuity  with  its  surroundings. 

Ribbert's  Theory. — Ribbert  ^  further  developed  the  idea  of 
displacement  of  cells.  According  to  his  view,  it  was  not  so 
much  development  as  post-natal  displacement  which  was  an- 
swerable for  cancer.  This  theory  has  undergone  so  many  modi- 
fications in  order  to  meet  criticism  that  it  is  not  easily  de- 
scribed.     He    held    that    displaced    cells    were    without    the 


f  CRTIUStt 


A  B 

Fig.  3. — Diagram  of  Cohnheim's  hypothesis.  The  different  behavior  of  the 
progeny  of  "rest"  A  and  "rest"  B  indicates  the  important  assumption 
which  the  hypothesis  entails.  The  necessity  for  this  assumption  was 
recognized  by  Cohnhelm  and  deUberately  made  by  him. 


restraining  influences  of  the  body,  and  therefore  simply  gave 
expression  to  their  natural  powers  of  growth.  Weigart  had 
argued  that  there  was  no  such  thing  as  a  stimulus  to  growth,  and 
Ribbert  accepted  the  view,  maintaining  that,  in  respect  of  their 
powers  of  growth,  cancer  cells  had  not  departed  from  the 
normal. 

It  cannot  be  denied  that,  following  injury  and  repair,  as 
well  as  inflammatory  conditions  of  all  kinds,  cells  are  often  dis- 
placed and  cut  off  from  their  normal  connections.  At  the  same 
time,  the  development  of  cancer  is  the  exception  and  not  the 
rule  under  these  circumstances.  Ribbert  sought  to  show  that 
very  early  growths  were  always  sharply  circumscribed  and  de- 
fined from  the  adjacent  tissue,  even  from  the  corresponding 

lEibbert,  Hugo.— "  Geschwiilste, "  Bonn,  1904. 


ETIOLOGY— THEORIES 


115 


epithelium.  Against  his  studies,  however,  must  be  placed 
reliable  observations  which  show  that  an  early  carcinoma  may 
maintain  continuity  with  the  normal  epithelium.  Ribbert  at- 
tached great  significance  to  the  occurrence  of  cellular  infiltra- 
tion in  the  connective  tissue  adjacent  to  early  carcinomata,  as 
being  evidence  that  changes  are  taking  place  in  the  connective 
tissue,  and  that  the  epithelium  never  grows  into  unaltered 
connective  tissue.  The  alteration  in  the  connective  tissue  is 
affected  by  chemical  substances  proceeding  from  the  epithelium. 
There  are  other  subsidiary  hypotheses,  one  of  which  is  that  the 


TtRTlLlStO 


jFig.  4.— Diagram  of  Ribbert's  hypothesis,  showing  the  manner  in  which  the 
differences  in  the  degree  of  differentiation  of  different  tumors  was  ex- 
plained by  him. 


new  connective-tissue  environment  effects  secondary  alterations, 
such  as  loss  of  differentiation,  in  the  carcinoma  cell. 

The  great  value  of  Ribbert's  theory  lies  in  the  stimulus  given 
by  it  to  the  study  of  the  earliest  stages  of  cancer  development, 
and  in  its  revelation  of  the  minute  size  of  the  area  within  which 
cancerous  changes  may  be  fully  demonstrated,  as  opposed  to  the 
theory  that  an  entire  organ  or  tissue  undergoes  transformation. 
Thus,  in  great  part,  was  built  up  the  theory  that  cancer,  once 
formed,  grows  from  its  own  resources  only,  and  not  by  accretion 
around  the  margins. 

Hauser's  Theory.- — Hauser  ^  put  forward  views  almost  cate- 
gorically different.     He  postulated  a  fundamental  biological 


1  Hauser,    Gustav. — * '  Das    Cylinderepithel. 
des  Dickdarms, "  Jena,  1890. 


Carcinom    des    Magens    und 


116  THE    CANCER    PROBLEM 

difference  between  normal  cells  and  cancer  cells,  the  latter,  in 
his  opinion,  being  a  ''new  race  of  cells,"  added  to  by  the  further 
production  all  round  the  margins  of  cells  of  the  same  kind.  lie 
reasoned  by  analogy  with  the  variations  in  individuals  and  the 
production  of  species.  He  saw  proofs  of  a  biological  change  in 
the  changed  microscopical  structure,  in  the  alterations  in  the 
size  of  the  cells,  their  nuclei  and  the  chromatin,  as  well  as  in 
the  increased  power  of  multiplication. 

Other  Theories. — Adami,  Benecke,  Marchand,  von  Hanse- 
mann,  and  others,  are  responsible  for  a  large  group  of  theories 
which  have  something  in  common  in  that  they  seek  to  explain 
the  power  of  grow^th  in  terms  of  loss  of  some  other  cell  function  ; 
for  example,  differentiation  and  secretion,  or  injury  to  one  part 
of  the  complex  cell  mechanism,  permitting  undue  manifesta- 
tion of  what  Adami  calls  the  "habit  of  growth." 

According  to  Adami,^  a  cell  which  has  lost  its  differentiation, 
or  which  has  never  acquired  it,  continues  to  take  up  nourish- 
ment, passes  into  an  active  vegetative  stage,  and  "gains  the 
habit  of  growth." 

Benecke  "  holds  that  the  lowering  of  functional  activity  is 
accompanied  by  increase  of  growth  energy. 

Marchand  ^  distinguished  sharply  between  the  undifferenti- 
ated embryonic  cell  and  the  undifferentiated  tumor  cell.  The 
former,  after  continued  growth,  undergoes  differentiation;  in 
the  latter  the  power  of  differentiation  has  not  only  become 
latent,  but  is  permanently  lost.  There  is  some  degeneration  in 
the  cell,  leading  to  faulty  metabolism,  and  the  exercise  of  toxic 
action  on  neighboring  cells  weakens  them  and  leads  to  their 
progressive  growth. 

Von  Hansemann,*  extending  the  work  of  Cornil,'^  Klebs,*' 
and  Podwyssozki  '^  on  cell  division  in  cancer,  described  in  detail 
the  irregularities  of  cell  division.  He  argued  that  these  must 
result  in  changed  biological  characters,  among  others  loss  of 
function  and  differentiation,  with  acquirement  of  increased 
powers  of  growth.  This  alteration  he  names  anaplasia,  and  as- 
serts that  it  is  not  a  theory  of  the  origin  of  cancer,  but  only  a 
description  of  actual  findings. 

Even  more  closely  identified  with  changes  in  the  nucleus  are 

*  Adami,  J.  George. — ' '  The  Principles  of  Pathology, ' '  London,  1909. 

2  Benecke. — Ziegler  's  Beitrage  zur  path.  Anat.,  1892-1893. 

'  Marchand. — See  General  Bibliography. 

■•Von  Hansemann,  David. — "Studien  iiber  die  Spezificitat,  den  Altruis- 
mus  und   die  Anaplasie  der  Zellen, "  Berlin,  1893. 

°  Comil. — See  General  Bibliography. 

'  Klebs,  E. — ' '  Handbuch  der  pathologischen  Anatomic, ' '  Berl.,  1869.  I, 
307. 

'Podwyssozki. — Ziegler 's  Beitrage  zur  path.  Anat.,  1886. 


ETIOLOGY— THEORIES 


117 


the  views  put  forward  by  Farmer,  Moore,  and  Walker,^  that 
the  cell  divisions  resemble  those  occurring  in  the  ripening  of 
the  sexual  cells.  These  views  lack  all  independent  confirma- 
tion, and  Bashford  and  Murray^  have  shown  the  sources  of 
fallacy  underlying  this  interpretation  of  the  chromatin  figures 
in  dividing  cells.  Oertel  ^  has  suggested  that  the  nuclear  chro- 
matin is  of  two  orders,  one  governing  function,  the  other  pro- 
liferation. By  the  loss  of  the  former  only  the  vegetative  prop- 
erties are  transmitted  to  future  cell  generations. 


Gametes 


Fig.  5. — Hypothesis  of  "gametoid"  nature  of  cancer  (Farmer,  Moore,  and 
Walker).  Cancer  is  assumed  to  arise  from  adult  tissues  in  a  manner 
analogous  to  that  by  which  the  normal  reproductive  tissues  are  separated 
from  the  soma  in  development.  The  properties  and  power  of  growth  of 
cancer  are  regarded  as  analogous  to  those  of  reproductive  tissue. 


PAEASITIC    THEORIES 


There  remains  for  consideration  the  theory  that  cancer  is 
caused  by  an  external  parasite.     This  view  has  long  been  held 

*  Farmer,  Moore,  and  Walker. — ' '  Resemblances  Exhibited  Between  the 
Cells  of  Malignant  Growths  in  Man  and  Those  of  Normal  Reproductive 
Tissue,"  Proc.  Roy.  Soc,  Vol.  72,  1903. 

'  Bashford  and  Murray. — ' '  On  the  Occurrence  of  Heterotypical  Mitoses 
in  Cancer,"  Proc.  Roy.  Soc,  B,  Vol.  77,  1906. 

'  Oertel,  Horst. — ' '  On  the  Heterogenesis  of  Tumors,  Particularly  Can- 
cer," JV.  r.  Med.  Jour.,  July  6,  1907. 


118 


THE    CANCER    PROBLEM 


in  various  forms,  and  a  legion  of  parasites  has  been  discov- 
ered. Not  one  of  these  has  found  anv  reasonable  amount  of 
support,  and  if  cancer  be  communicated  bv  such  means,  it  may 
safely  be  said  that  the  parasite  still  remains  unknown. 

The  grounds  on  which  cancer  is  held  to-day  to  be  infective 
are  mainly  statistical — the  increase  in  the  number  of  deaths 
from  it  recorded  throughout  the  world,  its  alleged  or  apparent 
higher  incidence  in  some  districts  than  in  others,  and  the  al- 
leged occurrence  of  ''cancer  houses.''     Alleged  epidemics  have 


FERTlLlStO 


Zr^ 


FCCTION 


ASx 


Fig.    6. — Parasitic  hypothesis. 
(The  numerous  aasumptions  entailed  are  discussed  in  the  text.) 


also  been  described  in  cows,  rats,  and  fish.  These  have  been 
dealt  with  in  the  section  on  Statistics. 

It  is  also  held  that  cancer  is  infectious  because  of  a  supposed 
resemblance  to  tuberculosis,  but  this  view  is  based  on  a  false 
analogy.  In  tuberculosis  the  tubercle  bacillus  is  the  cause  of 
the  disease,  the  bacillus  itself  being  transported  and  spreading 
throughout  the  body,  transforming  its  fresh  nidus  into  the 
tuberculous  process.  In  cancer,  as  is  discussed  under  Histo- 
pathology,  actual  portions  of  the  body  grow  in  places  where 
they  should  not  be,  having  themselves  been  transported.  Al- 
though the  use  of  the  term  is  hardly  permissible,  one  part  of 
the  body  has  become  parasitic  on  another  part. 

All  the  preceding  theories  may  be  placed  in  one  or  the  other 
of  two  categories.  It  is  assumed  that  an  external  stimulus  of 
some  kind  causes  gTowth,  or  it  is  assumed  that  some  change 


ETIOLOGY— THEORIES  119 

taking  place  internally  in  the  cell  itself,  permits  of  growth. 
The  parasitic  hypothesis  is  stated  in  both  ways  by  its  sup- 
porters. ^  The  alternatives  have  been  succinctly  expressed  by 
Powell  White, ^  who  is  not  a  supporter  of  the  parasitic  hy- 
pothesis : 

"If  the  continued  cell  proliferation  in  tumours  be  the  result 
of  direct  stimulation  by  an  extrinsic  irritant,  such  irritant  must 
of  necessity  be  a  living  organism,  since  the  proliferation,  being 
continuous  and  progressive,  demands  a  continually  increasing 
irritant.  This  applies  equally  to  the  histiomata  and  cytomata, 
and  since,  as  we  have  seen,  there  is  no  sharp  boundary  between 
the  two  classes  of  tumours,  we  must  infer  that  the  essential 
causal  factor  is  of  the  same  nature  in  both  cases.  The  supposed 
parasite  must  be  either  intra-  or  extracellular.  If  it  is  extra- 
cellular it  is  impossible  to  explain  the  absence  of  infection  of 
the  surrounding  tissues;  for,  as  we  have  seen,  the  growth  of  a 
tumour  is  the  result  of  proliferation  of  its  own  cells,  and  the 
surrounding  tissues  take  no  part  in  it,  except,  in  certain  cases, 
in  connection  with  the  area  of  origin.  ...  If,  on  the  other 
hand,  the  parasite  is  supposed  to  be  intracellular  it  would  seem 
necessary  to  suppose  that  the  division  of  the  cell  and  of  the 
parasite  was  so  timed  as  to  be  simultaneous,  each  daughter  cell 
receiving  a  daughter  parasite.  In  all  cases  in  which  parasites 
are  found  within  cells  the  effect  is  the  destruction  either  of  the 
parasite  or  of  the  cell. 

''Since  cell  proliferation  in  tumours  is  similar  to  cell  pro- 
liferation under  normal  conditions,  the  assumption  of  a  parasite 
to  explain  it  is  quite  unnecessary,  and  makes  an  explanation  of 
tumour  growth  more  difficult. 

"Direct  stimulation- of  cell  growth  by  a  parasite  is  an  un- 
known occurrence  in  biology  and  is  opposed  to  the  facts  of 
parasitism,  and  the  difficulty  is  not  avoided  by  applying,  as 
some  do,  the  term  symbiosis  as  explaining  the  association  be- 
tween the  supposed  cancer  parasite  and  the  organism.  In 
symbiosis  the  partners  receive  mutual  benefit  from  the  associa- 
tion, but  symbiosis  does  not  lead  to  proliferation. 

"Numerous  micro-organisms  have  been  described  by  differ- 
ent observers  as  occurring  in  cancers,  and  for  many  years  there 
has  been  a  great  controversy  between  those  who  uphold  and 
those  who  deny  that  cancer  owes  its  origin  to  one  or  more 
specific  parasites.  Investigation  has  been  carried  out  both  hy 
histological  and  by  cultural  methods  and,  at  different  times, 
bacilli,  cocci,  torulae,  protozoa,  myxomycetes,  spirochsetes,  nem- 

1  White,  Charles  Powell. — ' '  The  Pathology  of  Growth.  Tumourg. ' '  Lon- 
don, 1913. 


120  THE    CANCER    PROBLEM 

atode  worms,  and  acari  have  been  suspected  as  specific  organ- 
isms for  cancer,  but  no  organism  yet  described  has  stood  the  test 
of  criticism.  No  one  has  yet  isolated  from  cancers  any  organ- 
ism which  will  give  rise  to  cancer  when  inoculated  into  other 
animals,  except  the  cancer  cell  itself,  which,  as  we  have  seen, 
will,  under  suitable  conditions,  continue  to  live  and  produce 
cancer  when  grafted  into  an  animal  of  the  same  species  as  that 
from  which  the  cancer  was  derived.  Recent  observations  ap- 
pear to  show  that  it  is  possible  to  some  extent  for  cells,  both  of 
normal  tissues  and  of  cancers,  to  proliferate  in  vitro  as  do  bac- 
teria. Undoubtedly  bacteria  and  other  organisms  may  be  ob- 
tained from  cancers,  but  their  occurrence  is  apparently  acciden- 
tal, or  at  most  incidental,  as  they  do  not  stand  in  direct  causal 
relationship  with  the  cell  proliferation."  .  .  .  "We  have  seen," 
he  continues,  "that  we  cannot  ascribe  the  increased  proliferative 
capacity  of  the  cells  to  specific  parasites,  and  it  does  not  seem 
possible  in  any  other  way  to  explain  tumour  growth  by  the  as- 
sumption of  a  specific  causal  parasite.  It  is  impossible  to 
account  for  the  histiomata  on  this  basis,  and  it  is  equally  im- 
possible to  explain  the  complicated  tumours  such  as  blastocyto- 
mata,  teratomata,  and  compound  sarcomata.  There  only  re- 
main the  sarcomata  and  carcinomata,  and  even  in  these  cases 
the  assumption  of  a  specific  parasitic  origin  leads  to  numerous 
difficulties.     There  are  three  possibilities  to  be  considered. 

"(a)  There  may  be  a  single  parasite  for  sarcoma  and  car- 
cinoma. In  this  case  it  is  impossible  to  explain  the  regularity 
with  which  metastatic  tumours  repeat  the  structure  of  the  pri- 
mary. We  never  find  a  primary  carcinoma  giving  rise  to 
secondary  sarcomatous  tumours  as  we  should  expect  if  both 
were  due  to  the  same  causal  parasite. 

"(b)  There  may  be  one  parasite  for  sarcoma  and  another 
for  carcinoma.  Here  again  the  similarity  of  the  metastatic 
tumours  to  the  primary  provides  an  insuperable  difficulty.  If 
all  forms  of  carcinoma  were  due  to  a  single  parasite  we  should 
expect  the  metastases  in  the  liver,  in  some  cases  at  least,  would 
show  the  type  of  hepatic  carcinoma ;  this  does  not  occur. 

"(c)  Each  form  of  sarcoma  and  carcinoma  may  have  its  own 
specific  parasite.  Here  we  are  at  once  met  with  the  difficulty 
that  the  different  forms  of  these  tumours  are  almost  innumer- 
able, corresponding  to  the  innumerable  kinds  of  cells  in  the 
body.  While  they  may  be  reduced  to  a  limited  number  of  type 
forms,  yet  there  is  no  sharp  boundary  between  the  different 
groups,  and  there  is  considerable  variation  within  the  limits 
of  each  group.  We  should  have  to  suppose  a  different  set  of 
cancer  parasites  for  each  organ,   and  not  only  this,   but  we 


ETIOLOGY— THEORIES  121 

should  have  to  assume  a  different  series  of  parasites  for  each 
species  of  animal !  The  fact  that  tumours  are  found  in  all 
genera  of  the  higher  animals,  and  have  the  same  characters 
throughout,  and  yet  it  is  impossible  to  graft  a  tumour  from  an 
animal  of  one  species  into  another  animal  of  a  different  species, 
while  it  is  possible  to  do  so  within  the  same  species,  tells 
strongly  against  the  theory  of  a  parasitic  origin. 

"Other  difficulties  in  the  way  of  the  parasitic  theory  are 
found  in  the  close  relationship  of  the  cytomata  to  the  histiomata 
and  the  relationship  of  tumours  generally  to  malformations  and 
to  such  conditions  as  progressive  hypertrophy. 

"We  thus  see  that  the  assumption  of  a  specific  parasitic 
origin  for  cancer  leads  to  insuperable  difficulties  in  explaining 
the  observed  phenomena.  These  difficulties  entirely  disappear 
if  we  consider  the  cancer  cell  itself  as  a  parasite  and  cancer  as 
a  process  of  infection  by  cancer  cells." 

SUMMARY 

ISTaturally  all  older  theories  have  been  criticized  in  the  light 
of  the  extensive  experiments  that  have  been  performed  since 
the  beginning  of  the  present  century.  For  the  most  part  the 
net  result  has  been  to  show  that  all  theories  that  yet  have  been 
advanced,  constitutional,  parasitic,  or  strictly  cellular,  are  in- 
sufficient. The  true,  or  even  a  satisfactory  working  explana- 
tion of  the  nature  of  cancer,  has  not  yet  been  discovered. 


CHAPTER   II 
PREDISPOSING    CAUSES 

With  the  inauguration,  within  the  past  fifteen  years,  of  the 
^T^  of  experimental  cancer  research,  efforts  to  solve  the  prob- 
lem of  the  cause  of  cancer  have  assumed  a  character  different 
from  that  of  all  previous  investigation.  ISTone  of  the  theories 
of  the  past  concerning  the  essential  cause  having  proved  dem- 
onstrable, attention  has  nov7  come  to  be  more  or  less  confined 
to  the  determination  of  the  predisposing  factors — with  the 
hope  that,  in  thus  working  out  from  indirect  causes,  the  direct 
or  essential  cause  may  be  discovered. 

With  this  end  in  view,  an  enormous  amount  of  experimental 
work  has  been  done,  and  is  now  being  carried  on  in  the  various 
research  laboratories  of  the  world,  with  reference  to  the  in- 
fluence of  heredity,  irritation,  environment,  diet,  etc.,  upon 
the  production  of  this  disease.  Of  necessity  the  major  pro- 
portion of  these  investigations  has  been  made  with  short-lived 
animals,  such  as  are  available  for  laboratory  use.  Observations 
with  respect  to  the  various  predisposing  causes  of  cancer  hav- 
ing a  direct  bearing  upon  the  prevention  and  cure  of  the  dis- 
ease have  been  made,  however,  upon  human  subjects. 

The  Bearing  of  Experimental  Investigation  upon  Existent  The- 
ories.-— As  explained  in  the  section  on  Statistical  Considera- 
tions, breeding  experiments  with  mice  have  shown  that  a  lia- 
bility to  cancer  of  the  mamma  may  be  inherited,  but  it  is  not 
settled  whether  this  is  a  general  constitutional  liability  or  only 
a  predisposition  on  the  part  of  a  single  tissue.  The  balance  of 
evidence  favors  the  latter  view.  It  has  been  made  sufficiently 
evident  that  the  effect  of  heredity  is  slight,  and  not  of  itself 
sufficient  to  explain  the  development  of  cancer. 

The  parasitic  theory  has  received  no  support  from  experi- 
ment. Shortly  after  the  transplantation  of  cancer  in  mice  was 
demonstrated,    von    Leyden  ^    expressed    the    view    that    this 

ivon  Leyden,  E. — "  Ueber  die  parasitare  Theorie  in  der  Aetiologie  der 
Krebse,"  Berl.  Min.  Woch.,  1905. 

122 


ETIOLOGY— PREDISPOSING  CAUSES  123 

achievement  demonstrated  that  cancer  is  infectious.  The  opin- 
ion, however,  was  based  upon  a  misconception  of  the  process, 
and  upon  confounding  infection  with  transplantation.  By  in- 
fection is  understood  the  conversion  of  healthy  tissue  into  can- 
cerous tissue;  transplantation,  on  the  other  hand,  is  the  embed- 
ding of  ready-made  cancer  cells  into  a  healthy  animal  whose 
tissues  no  more  become  cancerous  than  does  the  soil  change  into 
geraniums  when  the  latter  are  planted  in  it. 

Borrel,^  a  firm  upholder  of  the  parasitic  nature  of  cancer, 
has  not  used  either  his  own  or  the  transplantation  experiments 
of  others  to  support  his  view.  He  relies  on  apparent  cage  epi- 
demics such  as  have  been  referred  to  elsewhere  (see  Section  VI, 
p.  152). 

Some  authors  have  thought  that  the  phenomena  of  immunity 
supported  the  parasitic  theory,  but  the  weight  of  authority 
goes  to  show  that  these  phenomena  have  no  analogy  with  what 
is  established  for  infective  diseases. 

Recently  Fibiger  ^  has  recorded  that  he  was  able  to  produce 
tumors  of  the  stomach  by  feeding  rats  with  cockroaches  in- 
fected with  nematodes.  Out  of  several  thousand  rats  experi- 
mented upon,  true  carcinomata  developed  in  three.  Some  have 
thought  the  nematodes  acted  as  the  carriers  of  a  virus  in  the 
way  that  Borrel  first  incriminated  them  for  mouse  tumors, 
because  of  the  frequency  with  which  he  found  nematodes  in 
the  lungs  of  that  animal.  Against  this  view  it  has  been  urged 
that  the  nematodes  were  not  certainly  shown  to  have  caused  the 
tumors,  of  which  they  may  have  been  mere  accompaniments,  or 
alternatively,  their  causal  relationship  was  merely  that  of  any 
other  chronic  irritant. 

The  congenital  or  embryonic  theory  of  the  origin  of  cancer 
has  received  no  support  whatever  from  the  experimental  and 
comparative  investigations  of  recent  times.  The  production  of 
cancer  by  irritants  is  determined  solely  by  the  point  to  which 
the  irritant  is  applied,  as  by  the  Kangri  in  Kashmir,  the  chew- 
ing of  betel  nut  in  other  parts  of  India,  and  the  harnessing  of 
a  wagon  to  the  right  horn  in  cattle.  To  assume  that  congenital 
germs  just  happen  to  be  present  at  the  point  where  the  irritant 
is  applied  is  a  needless  assumption. 

It  must  be  remembered,  of  course,  that  cancer  sometimes  de- 
velops in  a  congenital  anomaly,  for  example,  in  a  teratoma ;  but 

^Borrel,  A.— "Le  Probleme  du  Cancer,"  Bull,  de  I'Inst.  Pasteur,  1907, 
Vol.  V,  p.  497. 

^  Fibiger,  J. — ' '  Ueber  eine  durch  Nematoden  hervorgeruf  eiie  papillo- 
matose  u.  carcinomatose  Geschwiilstbildung  im  Magen  der  Eatte, ' '  Berl. 
Jclin.  Woch.,  1913. 


124  THE    CANCER    PROBLEM 

the  explanation  of  the  origin  of  cancer  there  is  jnst  as  difficult 
as  in  the  case  of  apparently  normal  adult  tissues. 

Experiment  has  shown  that,  after  transplantation,  tumors 
having  no  differentiation  at  all  do  not  progress  to  differentia- 
tion as  embryonic  tissue  does.  Moreover,  even  when  not  dif- 
ferentiated the  connective  tissue  or  stroma  usually  has  dis- 
tinctive characters  for  different  tumors.  If  cancer  were  merely 
undifferentiated  tissue,  one  would  expect  the  stroma  always  to 
show  a  uniform  character. 

On  the  constructive  side,  experiment,  while  revealing  a  very 
large  number  of  new  facts,  has  produced  very  little  in  the  way 
of  new  theories. 

Atreptic  Theory  (Ehrlich). — To  explain  his  experimental 
results,  Ehrlich  has  put  forward  the  atreptic  theory,  which  is 
a  sort  of  mixture  of  a  constitutional  and  a  cellular  theory.  In 
it  he  seeks  to  explain  the  increasing  frequency  of  cancer  with 
age  as  the  result  of  a  lessening  of  the  appetite  for  food  on  the 
part  of  the  body  as  a  whole,  while  certain  cells  retain  their 
normal  hunger,  or  at  least  lose  less  of  it  than  does  the  rest  of 
the  body,  Albrecht,"  without  performing  any  experiments,  had 
previously  put  forward  the  view  that  the  tumor  cells  acquired 
an  increased  avidity. 

It  must  be  remembered  that  Ehrlich's  theory  was  advanced 
early  in  the  development  of  recent  experimental  research,  and 
therefore  it  is  not  surprising  that  the  observations  on  which  it 
is  founded  are  not  regarded  as  reliable  by  some  other  investi- 
gators. It  is  based  on  the  following  facts  and  conclusions :  It 
is  difficult  to  transfer  a  primary  growth  to  new  animals.  The 
conclusion  was  therefore  drawn  that  this  was  because  the  avid- 
ity of  the  bodies  of  normal  animals  was  too  high  for  the  tumor 
cells.  Ehrlich's  transplanted  tumors  did  not  form  any  metas- 
tases, and  he  concluded  that  this  was  because  the  primary, 
transplanted  tumor  withdrew  to  itself  all  the  food,  thus  starv- 
ing the  cells  which  were  transported  to  the  lungs.     The  same 

1  Ehrlich,  P.,  and  Apolant,  H. — ' '  Beobachtungen  liber  maligne  Maiisen- 
tumoren, ' '  Berl.  klin.  Woch.,  July,  1905. 

Ehrlich,  P. — ' '  Experimentelle  Karzinomstudien  an  Maiisen, ' '  Zeitschr. 
f.  drtstliche  Fortbildung,  iii.     Jahrgang,  No.  7,  April,  1906. 

Also: 

' '  Experimentelle  Karzinomstudien  an  Maiisen, ' '  Arbeiten  aus  dem  Kgl. 
Instiiut  f.  exiJ.  Therapie,  Heft  I,  1906,  pp.  77-102. 

' '  Experimentelle  Karzinomstudien  an  Maiisentumoren, ' '  Zeitschr.  f. 
Krebsforschung,  1907,  Bd.  V,  Hefte  1  and  2,  pp.  59-80.  Abhandlung  der 
Internationalen  Konferens  fiir  Krebsforschung,  Heidelberg,  Sept.  25-27, 
1906. 

Ehrlich,  P.,  and  Apolant,  H. — "  Ueber  die  Genese  des  Carcinoms, " 
Ferhandl.  deutschen  Path.  Gesellsch.,  Zwolfte  Tagung,  Kiel,  1908. 

2  Albrecht,  E.  Rand. — "Bemerkung  zur  Geschwiilstlehre, "  Frankfurter 
Zeitschr.  f.  Pathologic,  Vol.  I,  1907. 


ETIOLOGY— PREDISPOSING  CAUSES  125 

explanation  was  given  as  to  why  he  could  not  reinoculate  a 
mouse  already  bearing  a  tumor.  Ehrlich  also  found  that 
mouse  tumors  would  grow  for  only  a  short  time  in  rats,  and 
he  concluded  that  this  was  because  the  tumor  cells  were 
starved  as  soon  as  the  foodstuffs  introduced  with  them  were 
used  up. 

All  investigators  are  agreed  on  the  difficulty  of  transferring 
a  primary  tumor  from  the  animal  in  which  it  was  produced 
to  a  normal  animal,  although  the  difficulty  appears  to  vary  with 
different  investigators  and  with  different  methods  employed. 
Bashford,^  for  example,  found  that  young  mice  gave  very  much 
better  results  than  did  old  mice,  a  fact  now  generally  admitted 
by  all  workers,  and  which  does  not  at  all  accord  with  Ehrlich's 
assumptions  as  to  the  part  played  by  bodily  avidity,  because 
the  contrary  result, should  then  be  obtained. 

Bashford  and  his  colleagues  have  recorded  a  large  number 
of  other  discoveries  quite  the  opposite  of  those  observed  by 
Ehrlich.  One  of  these  is  the  fact  that  metastasis  is  frequent 
in  their  experience.  They  also  explain  Ehrlich's  failure  to 
reinoculate  a  mouse  already  bearing  a  transplanted  tumor,  as 
due  to  active  immunity,  which  they  claim  to  have  fully  demon- 
strated. The  phenomenon  of  the  transitory  growth  of  mouse 
tumors  in  rats  they  explain  as  due  to  this  active  immunity,  re- 
sulting from  the  formation  of  a  true  cytotoxin,  such  as  is  pro- 
duced by  the  injection  of  the  blood  of  one  species  into  that  of 
another. 

Moreover,  the  demonstration  by  I.  B.  Murphy,^  of  the 
Rockefeller  Institute,  that  mouse  tumors  may  be  kept  growing 
through  a  long  series  of  hen's  eggs,  nullifies  entirely  Ehrlich's 
opinion  that,  because  of  inability  to  assimilate  foodstuffs  spe- 
cific to  mice,  mouse  tumors  grow  only  transitorily  in  rats. 

The  London  school,  consisting  of  Bashford,  Murray, 
Haaland,  Russell,  and  their  colleagues,  are  apparently  unwill- 
ing as  yet  to  identify  themselves  with  any  particular  theory  or 
hypothesis,  but  full  reference  to  their  work  is  reserved  for  the 
section  on  Modern  Cancer  Research.  At  one  time  Bashford 
and  Murray  ^  confirmed  certain  findings  by  Farmer,  Moore, 
and  Walker,*  to  the  effect  that  cancer  cells  had  forms  of  cell- 
division  similar  to  those  characteristic  of  the  ripening  of  sexual 
cells.     They  differed,  however,  from  the  conclusions  drawn  by 

1  Bashford,  Murray,  and  Bowen. — ' '  The  Experimental  Analysis  of  the 
Growth  of  Cancer,"  Proc.  Roy.  Soc,  B,  Vol.  78,  1906. 

^  Murphy,  I.  B. — ' '  Transplantability  of  Tissues  to  the  Embryo  of  For- 
eign Species,"  Jour,  of  Exp.  Med.,  1913,  p.  482. 

^Bashford  and  Murray,  op.  cit.    (p.  117). 

^Farmer,  Moore,  and  Walker,  op.  cit.    (p.  117). 


126  THE    CANCER    PROBLEM 

Farmer  and  his  colleagues,  and  subsequently  withdrew  their 
confirmation  of  the  findings  of  these  investigators. 

Chronic  Irritation. — Although  not  openly  expressed,  the  pur- 
pose which  apparently  lies  at  the  basis  of  all  the  work  of  the 
Imperial  Cancer  Research  Fund  is  an  attempt  to  explain  the 
association  of  many  forms  of  cancer  with  chronic  irritation. 
As  the  chronic  irritants  have  nothing  in  common,  it  is  held  that 
there  must  be  some  properties  in  cells  which  are  elicited  by 
chronic  irritation.  Chronic  irritation  leads  to  prolonged  or 
intermittent  irritation,  and  for  years,  in  propagating  tumors, 
Bashford  and  his  colleagues  have  demonstrated  that  many 
variations  in  structure  and  in  powers  of  growth  may  take 
place.  Just  as  what  they  describe  as  "new  tumors"  are  pro- 
duced during  propagation  by  cell  variation,  so,  they  leave  it  to 
be  inferred,  by  some  such  process,  or  a  similar  one,  cancer  is 
developed.  It  is  not  possible  to  define  their  position  with  any 
greater  precision  at  present.  (See  Section  VI, — Modern  Can- 
cer Research.) 

Among  the  views  recently  expressed,  mention  must  be  made 
of  the  remarkable  statement  of  Lazarus-Barlow,^  who  claims 
to  have  demonstrated  that  radium  is  present  in  larger  quanti- 
ties in  cancer  than  in  normal  tissues;  also  that  many  of  the 
irritants  associated  with  cancer,  like  the  clay  pipe,  or  gall- 
stones, are  radioactive.  These  views  are  based  on  highly  tech- 
nical experiments  and  require  confirmation. 

Opinions  differ  as  to  how  chronic  irritation  is  related  to 
cancer,  some  holding  that  it  merely  serves  to  make  an  entrance 
for  a  ubiquitous  cancer  parasite,  others  that  the  prolonged  cell 
proliferation  leads  to  cell  variation.  Notwithstanding  such 
divergent  points  of  view  as  regards  etiology,  one  of  the  most 
clearly  established  facts  about  cancer  is  its  production  in  tis- 
sues which  have  suffered  chronic  irritation,  often  of  long  dura- 
tion. This  association  is  naturally  most  often  observed  on  the 
surfaces  of  the  body;  for  example,  on  the  skii  and  mucous 
membranes.  The  irritants  are  manifold — chemical,  mechan- 
ical, actinic,  bacterial,  etc.  One  of  the  most  striking  instances 
is  that  of  the  development  of  cancer  in  a  tongue  attacked  by 
leukoplakia.  The  well-known  prevalence  of  cancer  of  the  scro- 
tum in  chimney-sweeps  is  due  in  some  way  to  soot ;  as  paraffin, 
tar  (Plate  III),  and  arsenic  are  causative  factors  in  other  cases. 

1  Lazarus-Barlow,  W.  S. — ' '  On  the  Presence  of  Radium  in  Some  Car- 
cinomatous Tumours  and  Other  Tissues, ' '  Arch,  of  the  Middlesex  Hosp., 
Vol.  XXVII,  1912.  "On  the  Presence  of  Radium  in  Some  Gall-stones  and 
on  a  Correlation  of  This  with  the  Frequency  of  Gall-stone  Occurrence  in 
Carcinoma, ' '  Ibid. 


ETIOLOGY— PREDISPOSING  CAUSES  127 

In  all  these  cases  there  has  been  long-standing  dermatitis  on 
which  warty  growths  appear.  In  the  bladder,  cancer  becomes 
superadded  to  the  papillomata  which  develop  in  anilin  workers 
or  in  bilharziosis.  Chronic  ulcers,  sinuses,  and  even  old  scars 
from  burns  may  undergo  cancerous  changes. 

On  the  surface  of  the  body  it  may  not  be  difficult  to  deter- 
mine that  there  has  been  chronic  irritation,  but  with  the  inter- 
nal organs,  of  course,  such  a  cause  is  far  more  difficult  to  estab- 
lish. For  the  stomach,  opin'^n  is  divided  as  to  the  etiological 
significance  of  chronic  ulcer  ^  for  the  biliary  and  urinary  pas- 
sages, the  same  is  true  with  reference  to  gall-stones  and  urinary 
calculi.  In  the  case  of  the  uterus,  previous  chronic  metritis, 
or  fissures  of  the  cervix,  have  long  been  present.  In  the  breast, 
however,  chronic  mastitis  may  never  have  been  detected,  and 
cancer  of  the  breast  may  develop  when  it  has  never  occurred. 
Certain  pigmented  moles  may  take  on  a  malignant  character 
either  in  consequence,  or  without  the  intervention,  of  irrita- 
tion. In  certain  instances,  as  when  cancer  develops  in  a  tera- 
toma or  sarcoma  in  the  retina,  it  is  very  difficult  to  determine 
the  part  played  by  chronic  irritation.  Simple  injury,  such  as 
a  blow  on  the  breast,  or  a  fracture,  may  be  followed  by  a  new 
growth ;  but  in  these  casfes  it  is  not  always  easy  to  de- 
termine whether  the  trauma  simply  draws  attention  to  an  al- 
ready existing  growth,  or  whether  it  exercises  a  causative  in- 
fluence. 

I  have  repeatedly  called  attention  to  the  importance  of  re- 
moving elevated  nevi,  papillomata,  adenomata,  and  other  be- 
nign growths  which  are  subject  to  chronic  irritation. 

Precancerous  Conditions.- — It  has  long  been  customary  to  use 
the  term  "precancerous"  with  reference  to  certain  conditions, 
notably  glossitis  and  dermatitis,  on  which  cancer  supervenes. 
In  Section  V  (Histopathology),  p.  133,  Butlin's  experience 
with  such  supposed  precancerous  conditions  of  the  tongue  is  re- 
lated. It  will  be  seen  that  five  out  of  seven  cases  were  proved  to 
be  early  carcinomata.  Therefore  it  has  seemed  to  the  author 
that  the  use  of  this  term  involves  the  danger  that  patients  or 
their  professional  advisers  may  be  encouraged  to  wait  until  can- 
cer has  developed  before  seeking  surgical  assistance,  and  that 
conditions  which  are  of  the  nature  of  chronic  inflammatory 
processes  predisposing  to  cancer  should  be  carefully  watched, 
and  any  minute  area  which  shows  the  changes  which  Butlin  in 
his  earlier  experience  would  have  called  "precancerous"  should 
be  treated  as  if  it  were  already  cancerous. 

Environment. — It  is  difficult  to  come  to  any  conclusion  re- 
garding the  etiological  influence  of  environment.     The  effect 


128  THE    CANCER    PROBLEM 

of  overcrowding  has  been  considered  in  the  sections  on  General 
Distribution  and  Statistics  (Chapters  II  and  III).  The 
different  liability  of  races  living  in  widely  separate  parts 
of  the  globe  ciinnot  be  determined.  Soil,  especially  chalk,  is 
held  by  some  authors,  whose  statistics  are  called  in  question  by 
others,  to  be  important  in  increasing  the  frequency  of  cancer. 
It  is  said  that  cancer  is  more  common  in  river  beds  than  on  ele- 
vated areas;  more  common  where  trees  grow  than  where  they 
are  absent.  It  is  held  to  be  more  frequent  in  the  central  pla- 
teau of  Europe  than  elsewhere.  But  all  these  statements  are 
of  the  nature  of  hearsay,  and  no  reliance  may  be  placed  upon 
them. 

The  one  form  of  environment,  however,  which  does  seem  of 
importance  in  connection  with  cancer  incidence  is  occupation. 
The  liability  of  different  parts  of  the  body  to  develop  either 
precancerous  or  cancerous  conditions,  in  consequence  of  ex- 
posure to  chronic  irritation  in  connection  with  certain  occupa- 
tions, is  fairly  well  established.  Workers  in  tar,  soot,  petro- 
leum, and  anilin  furnish  illustrations  of  this  contention.  This 
is  so  well  recognized  that,  in  England,  those  trades  in  connec- 
tion with  which  warty  growths  or  cancer  develop  are  scheduled 
as  coming  under  the  Workmen's  Compensation  Act.  In  some 
instances  it  is  not  the  occupation  so  much  as  the  liability  to 
alcoholism  that  is  held  to  be  responsible  for  the  development 
of  cancer. 

Diet. — The  question  of  diet  has  given  rise  to  a  great  deal  of 
discussion,  mostly  taken  part  in  by  extremists.  Hardly  an 
article  of  food  has  escaped  condemnation.  Salt,  tomatoes, 
coffee,  meat — especially  frozen  or  chilled  meat — pork,  and  al- 
cohol, all  come  under  the  ban.  But  the  possible  influence  of 
diet  is  shown  not  to  be  very  great  by  the  liability  to  cancer  of 
vegetarian  castes  in  India,  and  of  the  rice,  or  rice  and  fish-eat- 
ing Japanese.  Cows  never  eat  meat,  and  although  both  tame 
and  wild  mice  are  occasionally  cannibalistic  in  their  habits, 
they  do  not  come  in  contact  with  pork,  tomatoes,  or  alcohol. 
N^either  do  cows  or  other  herbivorous  animals  liable  to  cancer 
eat  their  vegetable  food  cooked.  Therefore,  it  seems  that  such 
sweeping  views  on  diet  as  are  published  from  time  to  time  in  lay 
papers  are  calculated  to  do  a  lot  of  harm. 

SUMMARY 

While  the  modern  experimental  investigation  of  cancer  has 
thrown  considerable  light  upon  certain  predisposing  factors  in 
the  production  of  cancer,  the  essential  cause  is  yet  to  be  dis- 


ETIOLOGY— PREDISPOSING  CAUSES  129 

covered.  Perhaps  the  most  practical  outcome  of  such  study  is 
the  emphasis  to  be  placed  upon  the  removal  of  all  possible 
sources  of  chronic  irritation,  and  of  benign  neoplasms  which 
are  subjected  to  irritation. 


SECTION    V 

HISTOPATHOLOGY 1 

DEFINITION 

The  difficulty  of  considering  cancer  apart  from  tumors  in 
general  is  as  great  with  regard  to  questions  of  classification 
and  structure  as  it  is  when  considering  the  disease  from  the 
clinical  point  of  view.  It  is  apparent,  of  course,  that  all 
tumors  or  swellings  are  not  malignant  new  growths ;  it  is 
equally  evident  that  malignant  new  growths — cancer— may  be 
present  when  no  swelling,  but  rather  an  actual  loss  of  tissue, 
exists.  Examples  of  the  latter  are  seen  in  the  shrinkage  which 
occurs  in  scirrhus  of  the  breast;  in  ulcer  formation,  as  in 
squamous-cell  carcinoma  of  the  tongue ;  and  in  rodent  ulcer  of 
the  skin. 

These  circumstances  explain  the  difficulty  of  defining  can- 
cer, as  they  do  that  of  defining  tumors  in  general,  particularly 
because  the  causation  of  both  is  unknown,  and  because  all  at- 
tempts at  a  sharp  separation  of  benign  from  malignant  new 
growths,  or  of  either  from  tumors  in  general,  meet  with  insur- 
mountable difficulties. 

Mere  hypertrophy,  or  overgrowth,  and  inflammatory  swell- 
ings, offer  greater  difficulties,  as  a  rule,  than  do  abscesses  or 
cysts,  although  the  latter,  in  certain  instances,  are  not  so  easy 
of  differentiation  as  abscesses,  and  may  be  malignant  in  nature. 
The  difficulties  are  further  enhanced  by  the  fact  that  hyper- 
trophy or  chronic  inflammation  may  precede  or  exist  alongside 
of  cancer,  which  may  be  superimposed  upon  such  conditions. 

In  genera],  hypertrophy  is  diffuse,  and  the  normal  arrange- 
ment is  maintained ;  whereas  a  tumor,  especially  a  malignant 

1  The  literature  of  histological  investigation  cannot  be  cited  in  a  book 
of  this  scope  without  serious  injustices  and  without  calling  forth  serious 
criticism.  A  very  full  literature  is  given  in  the  works  of  Borst  ("Die 
Lehre  von  dem  Geschwiilsten  mix  einem  mikroskopischen  Atlas. ' '  Two 
volumes,  Wiesbaden,  1902),  and  of  Ribbert  ("Gesehwiilstlehre  fiir  Aerzte 
und  Studirende, ' '  Bonn,  1904.  ' '  Das  Karzinom  des  Menschen,  sein  Bau, 
sein  Wachstum,  sein  Entstehung, "  Bonn,  1911),  to  which  the  reader  is 
referred. 

130 


HISTOPATHOLOGY  131 

new  growth,  is  localized  in  one  part  of  an  organ  whose  normal 
form  is  disturbed  thereby.  Acute  inflammation,  when  accom- 
panied by  a  swelling,  also  exhibits  other  clinical  features,  such 
as  rise  of  temperature,  pain,  etc.,  different  from  those  present 
in  the  case  of  a  true,  uncomplicated  tumor  or  a  cancer. 
Chronic  inflammation,  however,  owing  to  the  formation  of 
granuloma,  such  as  one  sees  in  syphilis,  tuberculosis,  or  actino- 
mycosis, may  be  associated  with  a  localized  increase  in  size. 
Such  tumors  often  present  great  difficulty  of  diagnosis,  more 
especially  because  the  process  of  chronic  inflammation  leading 
to  the  formation  of  granuloma  may  pass  on  to  true  malignant 
growth,  although,  as  a  rule,  with  the  removal  of  the  cause  such 
granuloma  formations  cease  to  increase  in  size  and  become 
absorbed. 

As  a  general  rule  tumors  grow  progressively,  although  this 
is  not  universally  the  case.  Some  cartilaginous  tumors,  for 
example,  found  at  the  ends  of  the  long  bones,  grow  only  during 
the  period  of  development  of  the  bones. 

It  will  thus  be  seen  that  it  is  difficult  to  define  a  true  tumor 
and  quite  impossible  at  present  to  give  an  exact  definition  of 
cancer.  Adami  ^  selects  Powell  White's  ^  definition :  "A 
tumour  proper  is  a  mass  of  cells,  tissues,  or  organs  resembling 
those  normally  present,  but  arranged  atypically.  It  grows  at 
the  expense  of  the  organism  without  at  the  same  time  subserv- 
ing any  useful  function."  Malignant  tumors,  in  addition, 
usually  exhibit  active  proliferation;  they  are  not  surrounded 
by  a  capsule,  but  fade  off  diffusely  into  surrounding  tissues  by 
virtue  of  their  property  of  infiltrative  growth ;  and  they  form 
fresh  centers  of  growth  at  a  distance,  owing  to  the  dissemina- 
tion of  cells  by  the  lymph  or  blood  stream. 

When  the  normal  structure  is  perfectly  reproduced,  or  if  it 
is  sharply  separated  from  surrounding  tissues  by  a  capsule,  the  i 
tumor  is  said  to  be  benign  or  innocent.  When  the  structure  is 
entirely  lost  and  only  a  mass  of  imdifferentiated  cells  is  to  be 
seen,  it  is  said  to  be  histologically  malignant.  It  must  be  dis- 
tinctly understood  that  these  are  merely  terms  of  convenience, 
and  that  the  biological  properties  of  the  tumor  determine 
whether  it  is  clinically  malignant  or  benign.  Some  tumors,  for 
example,  the  thyroid,  are  highly  malignant  and  yet  reproduce 
the  normal  structure  perfectly.  There  are  all  grades  between 
total  loss  and  complete  retention  of  structure. 

^  Adami,  J.  George. — * '  The  Principles  of  Pathology. ' '  Two  volumes. 
London,  1909. 

2  White,  C.  Powell. — "The  Pathology  of  Growth — Tumours."  London, 
1913. 


132  THE    CANCER    PROBLEM 

Practically  all  the  cells  and  tissues  of  the  body,  with  the 
probable  exception  of  nerve  cells/  are  liable  to  tumor  forma- 
tion and  to  the  development  of  malignant  new  growths.  The 
term  carcinoma  is  applied  if  the  malignant  growth  be  of  epithe- 
lial origin,  sarcoma  if  it  be  of  connective-tissue  origin. 

The  essential  feature  of  cancer,  whether  it  develops  in  a 
solid  organ  like  the  mamma,  or  on  the  covering  surface  of  the 
skin  of  a  hollow  organ,  is  the  continuous  proliferation  of  cells. 
Since  the  process  is  practically  the  same  for  all.  it  is  unneces- 
sary to  describe  it  in  detail  for  each  tissue. 


VALUE   OF  HISTOLOGICAL   STUDY 

Many  volumes  have  been  written  upon  the  minute  anatomy 
or  histology  of  cancer,  often  with  the  idea  of  setting  up  theories 
as  to  causation.  The  monumental  work  of  Borst,^  extending 
to  998  pages  of  print  and  293  colored  illustrations,  and  that  of 
Ribbert,^  amounting  to  G62  pages  and  590  figures,  may  serve  to 
show  the  mag-nitude  of  a  subject  which  may  be  only  briefly  sur- 
veyed here.  It  is  intended  to  convey  merely  the  essential 
anatomical  and  microscopical  features  of  the  disease ;  to  demon- 
strate its  relation  to  normal  tissues,  in  many  cases  its  origin 
from  them ;  its  mode  of  growth,  and  the  manner  of  its  dissem- 
ination throughout  the  body. 

The  microscopical  study  of  tumors,  of  their  relations  to  sur- 
rounding textures,  and  of  the  spread  of  such  of  them  as  are 
malignant  in  character,  has  had  a  profound  influence  on  con- 
ceptions of  the  nature  of  cancer,  its  origin,  and  its  treatment. 

It   should  be  more  fully  recognized  that  this  microscopic 

1  The  thyroid  gland  illustrates  this  difficulty  for  epithelial  tissues,  but 
the  development  of  secondary  growths  assists  in  arriving  at  a  definite 
conclusion,  which  is  not  possible  in  the  case  of  another  class  of  tumors — - 
in  those  developing  in  the  central  nervous  system.  These  tumors,  known 
as  glioma  or  as  gliosarcoma,  are  still  of  uncertain  origin.  Some,  by 
growing  progressively,  produce  a  tumor  whose  effects  may  be  described 
as  those  of  mechanical  pressure.  Others  grow  in  a  diffuse  and  infiltra- 
tive way  and  rot  only  involve  the  membranes  of  the  brain,  but  may 
even  penetrate  the  skull.  Under  the  microscope  these  gliomata  or  glio- 
sarcomata  have  the  appearance  of  what  is  held  to  be  the  connective  tissue 
of  true  nerve  cells,  but  there  is  still  discussion  as  to  whether  the  normal 
gland  is  an  epithelial  or  a  connective  tissue.  In  the  retina  so-called  glio- 
sarcomata  also  develop,  but  in  that  case  it  appears  not  to  be  doubtful 
that  they  are  really  careinomata. 

^  Borst,   Max. — ' '  Die   Lehre  von   dem   Geschwiilsten   mit   einem   mikro- 
skopischen  Atlas."     Two  volumes.     Wiesbaden,  1902. 

^Eibbert,  Hugo. — "  Geschwiilstlehre  fiir  Aerzte  und  Studirende, "  Bonn, 
1904.  "Das  Karzinom  des  Menschen,  sein  Bau,  sein  Wachstum,  sein 
Entstehung,"  Bonn,  1911. 


HISTOPATHOLOGY  133 

study  is  a  modern  method  of  investigation,  which  has  proceeded 
in  part  along  with,  and  in  part  subsequently  to,  the  employ- 
ment of  anesthetics  and  antiseptics  in  surgery ;  and  that,  to- 
gether with  them,  histology  has  placed  a  wide  gulf  between  the 
surgery  of  cancer  of  thirty  years  ago  and  surgery  as  it  is  prac- 
ticed to-day.  That  the  influence  of  the  study  of  the  minute 
anatomy  of  new  growths  is  still  spreading  is  shown  by  the  fol- 
lowing quotation  from  the  late  Sir  Henry  Butlin,^  who  did  so 
much  to  place  the  surgery  of  cancer  of  the  tongue  upon  a  scien- 
tific basis : 

"I  have  frequently  been  greatly  distressed  at  the  long  time 
during  which  actual  cancer  of  the  tongue  has  been  under  ob- 
servation before  either  the  medical  man  or  the  patient  has 
become  aware  of  the  gravity  of  the  disease.  But  I  never  knew 
until  two  years  ago  that  I  was  myself  guilty  of  failure  to  recog- 
nize cancer  of  the  tongue  in  its  earlier,  if  not  its  earliest, 
stages.  And  I  might  have  remained  in  the  same  condition  of 
ignorance  had  it  not  been  for  the  work  of  the  Imperial  Cancer 
Research  and  the  assistance  of  Dr.  Bashford  and  his  colleague, 
Dr.  Murray,  who  have  been  associated  with  me  throughout  the 
investigation  on  which  this  paper  is  based,  and  to  whom  I  am 
more  indebted  than  I  can  tell. 

"About  two  years  ago  Dr.  Bashford  asked  me  whether  I 
could  furnish  him  with  very  early  conditions  of  cancer  of  the 
tongue  for  the  Imperial  Cancer  Research.  I  replied  that  I 
would  certainly  do  so,  and  that  if  I  could  I  would  do  more 
than  this,  for  I  would  furnish  him  with  specimens  of  precan- 
cerous conditions  of  the  tongue,  so  that  he  might  study  the 
transition  into  actual  cancer.  .  .  . 

"Two  years  ago,  before  my  eyes  were  opened  by  the  work  of 
the  Imperial  Cancer  Rese'arch,  I  should  have  regarded  five  out 
of  the  seven  as  precancerous  conditions,  and  I  am  now  won- 
dering whether  there  are  really  any  conditions  perceptible  to 
human  sight  and  feel  which  are  precancerous  in  the  sense  in 
which  I  have  been  accustomed  to  employ  the  term. 

"Many  persons  will  wonder  why  I  have  been  so  slow  to  dis- 
cover the  true  nature  of  these  conditions.  I  can  only  answer 
that  I  am  humiliated  at  my  ignorance,  and  can  only  plead,  in 
excuse  for  it,  that  I  could  scarcely  ever,  a  few  years  ago,  per- 
suade patients  to  submit  to  operation  for  these  conditions. 
And,  if  I  had  removed  them,  it  is  quite  possible  that  their  real 
nature  might  have  been  overlooked  unless  they  had  been  exam- 

1  Butlin,  Sir  Henry. — ' '  Illustrations  of  Very  Early  Conditions  of  Can- 
cer of  the  Ton^e, "  Brit.  Med.  Jour.,  May  26,  1906.  (With  colored  plate 
of  clinical  appearances  and  histological  illustrations.) 


134  THE    CANCER    PROBLEM 

ined  in  continuous  sections  after  the  manner  which  is  now 
commonly  practised  in  the  investigations  of  cancerous  and 
douhtful  growths." 

These  conchisions  of  Sir  Henry  Butlin  were  accepted  by 
another  distinguished  surgeon  to  whom  he  showed  the  micro- 
scopical preparations.  In  view  of  their  far-reaching  impor- 
tance I  thought  it  necessary  to  inform  myself  of  the  exact 
nature  of  the  lesions  upon  which  they  were  based.  Owing  to 
the  lamented  death  of  Butlin,  application  was  made  to  Bash- 
ford,  who  had  prepared  a  series  of  sections  from  which  the 
drawings  of  an  early  cancerous  ulcer  of  the  tongue  (Plate  IV) 
were  made. 

HISTOLOGICAL    APPEARANCES 

The  microscopical  appearances  of  a  tumor  differ  according 
to  the  degree  with  which  the  normal  structure  is  reproduced  or 
is  departed  from.  When  the  tendency  is  to  reproduction  of 
the  normal  structure,  as  in  the  mamma,  the  cancer  cells  are 
arranged  in  groups  somewhat  after  the  manner  of  a  bunch  of 
grapes,  but  this  characteristic  of  the  normal  mammary  epithe- 
lium is  not  perfectly  reproduced.  The  structure  is  easily 
recognized  as  not  being  typical  of  the  gland,  and  varies  from 
one  area  to  another,  so  that  the  irregularity  of  the  arrangement 
dominates  the  picture. 

In  transverse  sections  the  natural  gland  spaces  or  lumina 
are  imperfectly  reproduced  and  are  often  of  irregular  shapes. 
Instead  of  being  of  uniform  size  they  may  show  wide  differ- 
ences in  this  respect.  The  lumen  of  the  normal  gland  may  not 
be  developed  at  all,  and  in  its  place  only  a  solid  mass  of  cells 
may  exist.  The  walls  of  the  liunina  are  formed,  not  by  a  single 
layer  of  cells,  but  by  two,  three,  or  more  layers.  When  cut 
lengthwise  the  glandular  tubules  present  similar  irregularities 
in  arrangement  and  size.  Their  branchings  and  their  connec- 
tions  one  with  another  depart  widely  from  the  normal,  and 
often  appear  as  if  determined  by  spaces  in  the  connective  tissue 
in  which  they  are  embedded.  The  masses  of  cancer  cells  may 
be  very  minute  or  they  may  form  relatively  large  masses  con- 
nected by  all  imaginable  branchings.  The  cells  may  be  closely 
pressed  together  in  solid  masses,  or  they  may  be  arranged  in  a 
single  layer  closely  approximating  to  that  of  the  normal  gland, 
and  all  intermediate  arrangements  may  be  observed.  The  cells 
themselves,  instead  of  being  uniform  in  size,  may  vary  greatly 
in  their  dimensions,  generally  tending  to  be  larger  than  normal. 

When  the  tendency  is  toward  an  entire  loss  of  structure,  the 


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Plate  IX. — Squamous-celled  carcinoma  (epithelioma)  spreading  by  permea- 
tion of  a  lymphatic  vessel,  of  which  the  hning  endothelium  is  still  partly 
retained. 


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Plate  XIII. — Invasion  of  along  bone  by  adeno-carcinoma  of  the  breast. 


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HISTOFATHOLOGY  135 

cells  are  closely  packed  together  in  solid  rods  or  narrow  bands 
embedded  in  dense  connective  tissue,  as  in  the  well-known 
scirrhus  of  the  breast,  or  they  occur  in  large  masses  much  less 
closely  packed  together,  with  a  fine  connective  tissue,  as  in  the 
typical  soft  or  medullary  cancers.  In  each  there  may  be  very 
little  or  absolutely  no  indication  of  the  normal  mammary  struc- 
ture. The  connective  tissue  varies  in  amount,  being  much 
more  or  much  less  than  normal.  It  carries  the  blood  vessels 
as  in  the  normal  gland.  The  vascularity  is  also  disturbed,  a 
great  increase  in  the  number  of  vessels  being  not  uncommon. 

The  general  arrangement  of  the  connective  tissue  and  of  the 
cancer  cells  gives  the  appearance  of  the  cells  being  contained 
in  spaces  in  the  connective  tissue.  These  spaces,  which  have 
been  termed  alveoli — corresponding  with  the  branchings  of  the 
masses  of  cancer  cells — naturally  communicate  one  with  an- 
other, so  that  the  whole  structure  resembles  that  of  a  sponge 
of  which  the  branching  tubules  would  represent  the  spaces 
filled  with  cancer  cells  in  the  case  of  a  malignant  tumor.  The 
relative  amount  of  connective  tissue  or  stroma  and  of  cancer- 
ous epithelium  has  led,  to  a  great  extent,  to  the  classification  of 
tumors  into  hard  and  soft,  or  scirrhous  and  medullary.  In 
scirrhous  cancer  of  the  breast  the  connective  tissue  dominates 
the  picture;  in  medullary  cancer  the  epithelial  cells  are  much 
the  more  abundant  element. 

All  sorts  of  intermediate  stages  may  be  noted  with  regard  to 
the  arrangement  of  the  epithelium,  its  approach  to  or  departure 
from  that  of  the  normal  gland,  and  the  amount  of  connective 
tissue.  An  abundance  of  solid  rods  of  cancer  cells  sparsely 
embedded  in  an  abundant  connective  tissue  gives  the  "typical" 
picture  of  scirrhus  of  the  breast — the  commonest  and  one  of 
the  most  dangerous  of  malignant  new  growths  (Plate  V).  With 
the  tendency  to  retention  of  structure,  there  may  be  a  diminu- 
tion in  the  amount  of  the  connective-tissue  element  (Plate  VI), 
but,  as  the  accompanying  figures  show,  even  where  the  pre- 
dominating histological  picture  tends  to  reproduce  the  struc- 
ture of  the  normal  mammary  gland,  the  growth  is  still  malig- 
nant, invading  and  destroying  adjacent  tissues,  and  disseminat- 
ing to  distant  parts  (Plates  VII,  VIII,  IX).  A  pure  adenoma 
would  be  regarded  as  benign,  but  the  term  adeno-carcinoma  con- 
veys the  difficulty  of  being  sure,  notwithstanding  the  micro- 
scopical structure,  that  the  growth  is  really  one  endowed  with 
malignant  properties,  as  the  figures  of  dissemination  by  way  of 
the  muscle  fibers  and  lymph  glands  clearly  show  (Plates  X,  XI, 
XII,  XIII). 

The  only  other  glandular  epithelia  for  which  illustrations 


136  THE    CANCER    PROBLEM 

of  the  cancerous  transformation  have  been  chosen  are  those  of 
the  liver  and  rectum  (Plates  XIV,  XV,  XVI,  XVII).  The 
accompanying  figures  illustrate  for  them  also  the  essential 
features  described  for  malignant  new  growths  of  the  breast. 
There  are,  however,  growths  of  which  the  structure  is  indistin- 
guishable from  the  normal,  and  which  nevertheless  are  highly 
maligTiant.  The  most  noteworthy  is  one  occurring  in  the  thy- 
roid gland  (Plate  XVIII).  Notwithstanding  its  complete  re- 
semblance to  the  normal  histology,  it  is  highly  malignant,  dis- 
seminating widely,  especially  in  the  bones.     (Plate  XVIII.) 

When  a  tumor  or  malignant  new  growth  occurs  on  a  surface, 
as,  for  example,  of  the  skin  or  intestine,  the  continuous  prolif- 
eration of  cells  leads  to  an  increase  in  surface  area,  which  may 
have  one  of  two  consequences.  This  increase  in  surface  area 
may  cause  a  bulging  outward,  with  foldings  of  the  growing 
area,  or  the  growing  portion  may  extend  below  the  surface.  In 
the  first  case  there  is  formed  a  wart-like  growth  or  papilloma 
(Plate  XIX).  Such  growths  are  often  benign,  but  are  by  no 
means  necessarily  so,  since  the  warty  outgrowth  may  be  com- 
bined with  a  malignant  down-growth,  for  example,  in  paraffin 
or  arsenic  cancer  of  the  skin,  in  cancer  of  the  lip,  in  papilloma 
of  the  bladder,  or  in  the  polypoid  growths  of  the  intestines, 
rectum,  and  uterus. 

When  growth  proceeds  downward  at  an  early  stage,  the 
continuity  with  the  normal  covering  epithelium  becomes  lost 
and  the  growth  is  sharply  defined.  The  definition  becomes 
more  clearly  marked  by  the  undermining  of  the  adjacent 
healthy  covering,  leading  to  its  exfoliation  and  the  formation 
of  an  ulcer  over  the  tumor  cells.  The  simplest  case  is  that  of 
the  squamous  epithelium  covering  the  tongue  where  the  hairs 
and  glands  are  absent,  their  presence  complicating  the  picture 
for  the  skin  itself  (Plates  XX,  XXI,  XXII).  The  squamous 
epithelium  growing  downward  produces  large  masses  of  an  ir- 
regular branching  nature,  sometimes  like  enlarged  and  ab- 
normal papilla  of  the  skin,  but  often  rounded  or  so  divided  up 
as  to  have  no  connective  tissue.  In  the  center  of  these  masses 
the  differentiation  to  a  resemblance  to  horny  material,  or  kera- 
tinization,  gives  a  characteristic  picture.  This  condition  is 
due  to  the  cells  not  being  now  on  a  free  surface,  owing  to  the 
atypical  growth.  The  cells  become  arranged  concentrically,  the 
keratin  being  in  the  middle.  The  appearance  is  characteristic, 
and  is  known  as  pearl  formation. 

An  exceptional  position  is  occupied  by  one  of  the  most  fre- 
quent forms  of  cancer  of  the  skin,  especially  of  the  face,  namely, 
rodent  ulcer  (Plate  XXIII).  For  a  long  time  it  was  considered 


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Plate  XX. — Margin  of  squamous-celled  carcinoma  (epithelioma)  of  tongue.  Note 
the  down  growth  of  the  mahgnant  epithelium,  its  continuity  with  healthy  epi- 
thelium, its  liabihty  to  ulceration. 


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HISTOPATHOLOGY  187 

doubtful  whether  or  not  rodent  ulcer  really  was  a  malignant 
new  growth.  It  usually  starts  in  a  small,  wart-like,  red  pimple. 
This  speedily  breaks  down,  forming  an  ulcer,  which  gradually 
spreads  and  which  may  attain  huge  dimensions.  The  cells  are 
devoid  of  all  differentiation  and  present  a  peculiar  "thatched" 
arrangement.  The  tissue  of  origin  is  still  the  subject  of  de- 
bate, the  skin  itself,  the  hair  follicles,  the  sebaceous  and  the 
sweat  glands  all  being  suggested  as  the  mother  tissue  (Plate 
XXIII). 

CLASSIFICATION 

As  stated  above,  practically  every  tissue  of  the  body  is  liable 
to  tumors  and  to  cancer.  This  liability  forms  to-day  the  basis 
for  the  best  working  classification;  but  to  understand  how  it 
has  come  to  serve  this  end  it  is  necessary  to  review  briefly  how 
knowledge  of  normal  and  pathological  histology  gradually  de- 
veloped. 

The  original  application  of  the  term  "cancer"  (Greek  harhi- 
nos;  Lat.  cancer)  is  shrouded  in  mystery.  It  would  appear 
that  as  certain  plants  had  terms  applied  to  them,  like  lungivort 
and  liverwort,  because  of  some  fancied  resemblance  to  the  lung 
or  liver,  so,  also,  some  resemblance  to  a  crab  was  imagined  for 
certain  tumors.  The  term  "cancer,"  as  we  have  already  noted, 
appears  to  have  been  applied  originally  to  cancer  of  the  breast, 
in  which  case  the  enlarged  blood  vessels,  sometimes  evident  as 
radiating  in  the  skin  from  the  tumor,  may  be  said  to  resemble 
the  limbs  extending  from  each  side  of  a  marine  crab.  The 
origin  of  the  term  is  of  little  moment,  but  it  is  important  to 
note  that  at  first  it  had  no  reference  to  anatomical  or  micro- 
scopical structure,  being  applied  clinically,  and  that  it  con- 
tinued to  be  solely  so  applied  until  the  middle  of  the  last  cen- 
tury, or  up  to  the  time  of  Virchow,  when  the  development  of 
morbid  anatomy  and  of  the  microscopical  study  of  the  tissues — 
histology — opened  the  discussion  as  to  what  was  actually  meant 
by  "cancer." 

In  ancient  literature  there  are  such  excellent  descriptions 
of  clinical  appearances,  notably  for  the  uterus  and  the  breast, 
that  it  can  scarcely  be  doubted  that  they  refer  to  conditions 
similar  to  those  to  which  the  term  "cancer"  is  applied  to-day. 
But  there  does  not  occur,  so  far  as  I  have  been  able  to  ascer- 
tain, a  single  description  of  the  naked-eye  appearances  to  be 
seen  on  cutting  across  a  malignant  new  growth,  say  a  scirrhu? 
of  the  breast.  The  old  separation  into  scirrhus,  fungus  hema- 
todes,  etc.,  was  based  upon  superficial  or  other  clinical  features, 


138  THE    CANCER    PROBLEM 

and  rodent  ulcer,  for  example,  was  so  named  because  it  was 
not  recognized  as  a  form  of  cancer. 

Accurate  descriptions  of  the  morbid  anatomical  and  of  the 
microscopical  or  histological  appearances  are  of  quite  modern 
date,  and  are  contemporary  with  the  development  of  micro- 
scopical technic,  section  cutting,  and  section  staining.  Prior 
to  1875,  sections  were  usually  obtained  without  previous  hard- 
ening (except  freezing),  and  without  impregnation  in  an  im- 
bedding material,  and  were  examined,  as  a  rule,  unstained,  in 
water  or  glycerin,  or  after  the  application  of  acetic  acid,  caus- 
tic soda,  or  teasing  or  shaking.  Many  of  the  terms  still  in  use 
owe  their  origin  to  these  primitive  methods,  notably  the  use  of 
the  term  ''alveolus"  to  describe  the  space  in  which  the  cancer 
cells  are  held  by  a  surrounding  connective  tissue.  But  the  rela- 
tion of  the  fibrous  tissue  to  the  cancer  cells  was  difficult  to 
settle  by  these  crude  methods,  and  led  to  the  view,  held  by 
Johannes  Miiller  and  Virchow  among  others,  that  the  connec- 
tive tissue  was  the  all-pervading  matrix  out  of  which  both  the 
normal  and  cancer  cells  developed,  as  it  were,  by  crystalliza- 
tion. Many  years  of  discussion,  and,  notably,  the  development 
of  embryology,  were  necessary  before  the  true  relation  between 
connective  tissue  and  epithelial  tissue  was  made  clear,  espe- 
cially by  His.  Working  with  this  new  knowledge,  Thiersch 
and  Waldeyer  were  able  to  establish  definitely  that  Virchow 
and  his  predecessors  were  wrong  in  the  opinion  which  they 
held  as  to  the  development  of  normal  and  cancer  cells  out  of  a 
connective-tissue  matrix.  As  is  now  well  kno^vn,  the  epithelial 
and  the  connective  tissues  arise  side  by  side  in  the  embryo  at  a 
very  early  stage.  Moreover,  the  view  upheld  by  His,  that  the 
several  tissues  are  specific  and  do  not  pass  over  into  one  an- 
other, except  in  a  few  rare  instances,  and  within  narrow  limits 
(metaplasia),  has  been  firmly  established. 

These  facts  will  make  it  evident  why  we  have  to  study  can- 
cer in  connection  with  the  site  and  tissue  in  which  it  takes  its 
origin.  Since  practically  every  tissue  of  the  body  is  liable  to 
tumors  and  to  cancer  in  several  forms,  the  histological  study 
of  tumors  and  cancer  is  an  even  more  complicated  process  than 
the  microscopical  study  of  normal  tissues.  Nevertheless,  the 
only  useful  classification  of  tumors  and  malignant  new  growths 
is  a  histological  one.  By  employing  it,  questions  of  etiology 
are  avoided.  Ultimately,  when  causation  has  been  elucidated, 
it  will  form  the  rational  basis  of  classification. 

Thus  it  comes  about  that  simple  tumors  are  named  after  the 
tissues  of  which  they  are  solely  or  mainly  composed.  Tumors 
of  more  complex  structure  are  named  by  combinations  of  the 


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Plate  XXVII. — Spindle-ceUed  sarcoma. 


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Plate  XXX. — Melanotic  sarcoma.  Secondary  in  liver,  showing  fatty  degenera- 
tion of  liver  cells  and  pressure  effects  on  the  liver.  Also  natm-al  size  showing 
number  of  secondary  nodules  in  a  small  piece  of  liver. 


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Plate  XXXIII. — Structure  of  subcutaneous  capillary  nevus,  or  birthmark.  In 
the  capillary  spaces  are  seen  blood  corpuscles.  Such  a  nevus  may,  under 
chronic  irritation  or  from  an  unknown  cause,  become  a  malignant  growth. 


Plate  XXXV. — Chorion  epithelioma  of  uterus.  This  is  a  somewhat  rare  and  highly 
interesting  gi-owth  arising  during  pregnancy.  It  gives  rise  to  numerous  secon- 
dary growths  which  often  exhibit  the  remarkable  phenomenon  of  spontaneous 
heahng.  The  tumor  is  invading  the  muscles  of  the  uterus.  It  shows  the  char- 
acteristic structure  of  the  two  epithelial  layers  of  the  chorionic  villus,  viz.,  the 
outer  darkly  staining  syncytial  layer  without  definite  cell  boundaries,  giving 
rise  to  plasmodial  masses,  and  the  deeper  layer  of  Langhans,  consisting  of  large 
clear  cells.    The  spaces  are  usually  filled  with  blood. 


HISTOPATHOLOGY  189 

terms  applied  to  the  tissues  comprising  them.  The  most  com- 
plex tumor,  in  all  probability,  is  the  teratoma,  which  is  the 
result  of  the  inclusion  of  portions  of  an  imperfectly  developed 
twin  in  the  fully  developed  organism.  When  the  tumor  of  any 
tissue  departs  largely  from  the  normal  structure,  it  is  known  as 
a  carcinoma  of  the  epithelial  tissue  or  organ  of  origin,  and  as 
a  sarcoma,  if  it  arise  in  connective  tissue.  Tumors  which  ap- 
parently arise  from  the  endothelium  covering  serous  surfaces, 
or  lining  lymph,  and  blood  vessels,  are  known  as  endothelioma. 
The  following  tumors  are  named  in  accordance  with  their 
tissue  of  origin :  ^ 

Fibrous  tissue  Fibroma 

Cartilage  Chondroma 

Bone  Osteoma 

Eed  marrow  Myeloma 

Muscle  Myoma 

Fat  Lipoma 

Mucous  tissue  Myxoma 

Dental  tissue  Odontoma 

ISTerve  ]^euroma 

Glia  of  nervous  system  Glioma 

Lymphatic  gland  or  tissue  Lymphoma 

Blood  vessel  Angioma 

Lymph  vessel  Lymphangioma 

Resembling  any  gland  Adenoma    of    the    particular 

gland 

Resembling      wart      or  out-      Papilloma  or  polypus  of  the 

growth.  particular  site. 


In  the  case  of  the  connective-tissue  tumors  which  are  malig- 
nant, i.  e.,  sarcomata,  the  adjective  malignant  may  be  prefixed. 
Usually,  however,  the  idea  of  malignancy  is  conveyed  by  com- 
bining the  terms  given  above  with  sarcoma,  thus,  osteosar- 
coma, fibrosarcoma.  Similarly,  when  it  is  intended  to  convey 
the  idea  of  malignancy  of  a  tumor  of  a  gland,  carcinoma  is 
combined;  thus,  adenocarcinoma  of  the  breast,  stomach,  rec- 
tum, or  other  organ  of  origin. 

The  connective  tissue  of  a  tumor,  as  explained  below,  is 
partly  inherent  in  the  tumor  itself,  it  is  partly  derived  from 
the  preexistent  connective  tissue  of  the  surroundings,  and  it  is 
partly  a  new  formation.    All  connective  tissues,  with  the  excep- 

^  Illustrations  of  many  of  these  appear  in  the  foregoing  Plates,  as  well 
r,s  in  Plates  XXIV  to  XXXV. 


140  THE    CANCER    PROBLEiM 

tion  of  bone  and  cartilage,  may  serve  as  a  scaffolding,  and  their 
nature  and  amount  may  lead  to  tumors  being  classified,  for 
exiimple  when  fibrous  tissue  forms  an  important  part  of  the 
growth,  as  fibrosarcoma,  fibrolipoma,  or  fibro-adenoma.  When 
both  the  epithelial  and  connective-tissue  components  of  a  tumor 
exhibit  malignant  properties,  it  is  customary  to  speak  of  a 
mixed  tumor  or  a  carcinoma-sarcomatodes. 


ORIGIN   AND   SPREAD 

Histological  study,  confirmed  by  the  experimental  inocula- 
tion of  cancer  cells,  has  now  definitely  established  that  cancer 
arises  in  a  minute  circumscribed  area  where  a  progressive 
proliferation  of  cells  takes  place.  There  is  usually  only  one 
center  of  growth,  but  there  may  be  several,  which  ultimately 
coalesce  within  a  minute  area.  It  is  rare,  and  indeed  it  has 
been  denied,  that  cancerous  transformation  of  an  entire  organ 
occurs.  It  must  be  remembered  that  histological  study  tells  us 
little  or  nothing  as  to  the  biological  change  which  starts  the 
cancerous  proliferation. 

The  consequences  of  the  progressive  proliferation  are  local 
and  remote.  A  lump  may  form  locally,  or  an  ulcer  may  de- 
velop. The  lump  is  found,  on  microscopical  examination,  not 
to  be  encapsulated,  and  the  ulcer  is  not  sharply  defined  at  its 
base  and  sides ;  both  fade  off  into  the  surrounding  tissues  be- 
cause they  have  been  infiltrated  by  the  growing  cells.  Actual 
destruction  of  tissue  may  have  occurred,  especially  of  a  cover- 
ing skin  or  mucous  membrane,  of  a  bone  or  of  a  cartilage. 
These,  although  not  affording  a  scaffolding  for  cancer  cells,  as 
does  connective  tissue,  do  not  become  incorporated  in  the  malig- 
nant growth.  The  cancer  cells  penetrate  between  and  destroy 
muscle  fibers  by  pressure,  thus  causing  disorganization  of 
muscles.  The  columns  of  cancer  cells  may  actually  spread  along 
inside  the  sheath  of  the  muscle  fibers.  They  get  into  the  blood 
vessels,  especially  the  veins,  the  stronger  elastic  coat  of  the 
arteries  being  more  resistant.  They  spread  along  the  lymphatic 
channels  either  with  or  against  the  lymph  stream.  Both  in 
the  veins  and  lymphatics  particles  may  be  carried  away  and 
lodged  in  distant  parts,  or  growth  may  take  place  by  conti- 
nuity, as  described  by  TIandley  in  his  "lymphatic  permeation" 
theory.  (See  Section  XI,  Chapter  2.)  These  growing  points, 
as  it  were,  thus  proceed  ever  farther  and  farther  from  the 
parent  tumor. 

Eemote  consequences  may  occur,  therefore,  anywhere ;  but 


HISTOPATHOLOGY  141 

their  relative  frequency  in  any  particular  site  is  determined 
by  the  lymphatic  or  vascular  connections  of  the  site  or  organ 
primarily  attacked.  Thus,  owing  to  the  fact  that  the  cancer 
cells  are  carried  to  the  liver  by  the  portal  system  after  they 
have  entered  the  large  veins  in  the  submucous  tissue  of 
the  bowel,  the  liver  is  the  common  site  of  secondary  growths 
from  the  rectum  or  the  intestines.  The  lung  is  another  fre- 
quent site  for  secondary  growths,  extension  in  this  case  taking 
place  through  the  lymphatics  or  blood  vessels,  or  through  the 
blood  stream  by  way  of  the  thoracic  duct  When  extension 
takes  place  through  the  lymphatic  channels,  the  lymphatic 
glands  are  attacked  in  consequence. 

Some  growths  manifest  a  tendency  to  the  formation  of  sec- 
ondary deposits  in  the  bones.  Thus  colonies  arise  from  trans- 
planted cells  and  then  reproduce  in  their  new  surroundings  all 
the  features  of  the  primary  growth,  so  that,  as  it  has  been 
briefly  expressed,  a  piece  of  rectum  is  found  growing  in  the 
liver,  liver  in  the  lungs,  mamma  in  lymph  glands  or  bones,  and 
skin  in  lymph  glands  or  lungs.  These  exhibit  also  all  the  de- 
structive and  infiltrative  properties  of  the  primary  growth, 
invading  in  their  turn  and  destroying  the  tissues  of  the  im- 
portant organs  in  which  they  have  established  themselves,  caus- 
ing the  destruction  of  blood  vessels  and  giving  rise  to  hemor- 
rhages, leading  to  ulcerated  surfaces  and  to  abscesses,  destroy- 
ing bone  and  leading  to  spontaneous  fractures,  settling  in  the 
brain  and  producing  unconsciousness  and  other  disturbances. 


BASIS    OF   SURGICAL   TREATMENT 

Thiersch  and  Waldeyer  demonstrated  that  carcinomata  are 
derived  from  preexisting  epithelium,  and  not,  as  held  by  Vir- 
chow,  from  connective  tissue.  They  thus  dealt  the  last  and 
final  blow  to  the  old  views  concerning  the  constitutional  nature 
of  the  disease — views  which  had  caused  surgeons  to  despair  of 
successfully  treating  a  ''blood  disease"  by  surgery.  The  first 
consequence  of  this  change  of  view  was  the  establishment  of 
the  fact  that  the  secondary  growths  which  appear  in  other  parts 
of  the  body  are  the  result  of  the  transplantation  there  of  cells 
from  the  original  focus,  thus  setting  up  a  fresh  colony,  and 
that  they  are  not  the  result  of  some  influence,  proceeding  from 
the  primary  tumor  or  pervading  the  constitution,  w^hereby  a 
transformation  is  effected  in  the  normal  tissues  of  the  parts 
so  attacked. 

Thus  the  surgical  treatment  of  cancer  came  to  have  a  rational 


142  THE    CANCER    PROBLEM 

basis,  namely,  the  removal  of  the  primary  focus  before  any 
spread  had  taken  place,  or,  at  any  rate,  before  it  had  extended 
beyond  the  immediate  neighborhood.  Waldeyer  ^  recommended 
the  removal  of  the  entire  mammary  gland,  because  he  thought 
if  one  part  of  an  organ  had  shown  itself  liable  to  cancerous 
change,  then  the  rest,  if  left  behind,  would  likewise  ultimately 
undergo  a  similar  change.  Since  that  time  the  doctrine  of  the 
circumscribed  area  within  which  cancer  arises  has  been  estab- 
lished as  the  general  rule,  and  to-day  the  surgical  practice  of 
wide  removal  is  based  not  so  much,  and  often  not  at  all,  upon 
the  fear  of  the  liability  of  the  organ  as  a  whole  to  the  disease, 
as  upon  the  recognition  of  the  necessity  for  removing  the 
primary  focus,  together  with  all  the  tissues  to  which  there  is 
any  possibility  of  its  having  already  sent  offshoots.  As  long 
ago  as  1867,  Charles  Moore  -  was  of  the  opinion  that  recur- 
rence after  an  operation  was  not  due  to  constitutional  taint  or 
to  cancer  being  a  "blood  disease,"  but  to  incomplete  removal  of 
the  primary  tumor  and  its  secondary  offshoots.  It  will  be 
remembered  that  this  view  was  put  forward  before  Lister  had 
triumphed  over  sepsis.  It  is  therefore  not  surprising  that  the 
view,  and  the  extensive  operation  which  Moore  based  upon  it, 
met  with  strong  opposition  for  years.  In  a  great  debate  in 
1874,  before  the  Pathological  Society  of  London,  the  above 
innovations  were  hotly  contested.^  The  late  Sir  James  Paget, 
among  others,  championed  the  constitutional  or  "blood  disease" 
theory  as  against  the  circumscribed  origin  upheld  by  Moore  and 
de  Morgan.  Since  that  time  correlated  histological  study  and 
surgical  achievement  have  established  the  fact  that  cancer 
arises  in  a  minute  area  which  can  be  excised,  and  that  by  thus 
removing  this  area  the  patient  may  be  cured.  The  experiments 
of  the  Imperial  Cancer  Research  Fund  have  proved  that  all 
the  features  of  the  disease  can  be  reproduced  by  implanting  the 
minutest  fragment,  thus  giving  additional  foundation  for  mod- 
ern surgical  practice  as  applied  to  cancer. 


SUMMARY 

The  development  of  knowledge  concerning  the  histopathology 
of  cancer,  and  the  experiments  which  have  proved  the  trans- 

*  Waldeyer,  W. — "Ueber  den  Krebs, "  Vollkmann's  Sammlung  Minischer 
Yortroge,  No.  33,  1872. 

2  Moore,  Charles. — ' '  On  the  Influence  of  Inadequate  Operations  on  the 
Theory  of  Cancer,"  Trans.  Royal  Med.  Cliir.  Soc,  London,  1867. 

3  Trans.  Path.  Soc.  of  London,  Vol.  XXV,  1871. 


HISTOPATHOLOGY  143 

plantability  of  cancer  tissue,  have  had  a  most  important  bear- 
ing upon  the  treatment  of  the  disease,  establishing,  beyond 
question,  the  view  that  the  complete  surgical  removal  of  the 
primary  focus  results  in  the  eradication  of  the  malignant 
process  and  in  the  cure  of  the  patient.  It  is  therefore  greatly 
to  be  regretted  that  the  public  is  encouraged  to  give  ear  to  old 
discarded  views  which  to-day  are  still  put  forward  as  if  they 
were  new,  and  which  appeal  with  especial  force  to  the  ignorant 
and  to  the  timid  who  fear  ''the  knife." 


SECTION    VI 

CANCER   RESEARCH— A   RESUME   OF   THE 
WORLD'S   WORK 

PRACTICAL    RESULTS 

The  Failure  of  Modern  Experimental  Study  of  Cancer  to  Estab- 
lish the  Etiology  of  the  Disease. — Before  considering  the  net 
results  of  the  modern  experimental  investigation  of  cancer,  it 
is  well  to  recall  the  fact  that  in  the  essential  matter  of  etiology 
no  entirely  new  or  revolutionary  conceptions  have  been  evolved. 
Cancer  continues  to  offer  an  exception  to  the  general  rule  of 
the  gradual  change  in  the  prevailing  views  concerning  the 
causation  and  treatment  of  diseases.  It  likewise  fails  to  come 
within  the  category  of  the  revolutionary  change  in  the  concep- 
tion of  etiology  and  treatment  which  has  marked  the  discovery 
of  the  infective  nature  of  many  diseases. 

Dominated  for  centuries  by  primitive  humoral  ideas  of  dis- 
ease, it  was  only  in  the  middle  of  the  nineteenth  century,  and 
largely  owing  to  the  work  of  Virchow,  that,  by  observation, 
facts  were  established  on  a  basis  sufficient  to  permit  students 
of  morbid  anatomy,  and,  later,  students  of  morbid  histology,  to 
pursue  paths  of  their  own. 

Leaving  medieval  dogma  and  humoral  conceptions  of  cancer 
out  of  all  account,  and  considering  only  those  hypotheses  which 
are  of  modern  importance,  there  has  been,  in  the  whole  medical 
history  of  cancer,  no  more  dramatic  clash  of  theory  with  fact 
than  that  which  caused  Virchow  ^  to  cease  the  publication  of  his 
''Onkologie"  (see  Section  IV,  Chapter  1,  p.  108),  in  conse- 
quence of  the  appearance  of  the  papers  of  Thiersch,-  whose 
views  were  confirmed  and  extended  by  those  of  Waldeyer.^  That 

^Virchow,  Eudolph.— " Die  Krankhaften  Geschwiilste, "  Berl.,  1863,  Vol. 
II,  Onkologie,  Part  I. 

^  Thiersch,  Carl. — ' '  Der  Epithelialkrebs,  namentlieh  der  Haut.  Eine 
anatomisch  klinische  Untersuchung.  Mit  einem  Atlas  mikroseopischer 
Abildimgen, "  Leipz.,  1865. 

'  Waldeyer,  W. — ' '  Die  Entwicklung  der  Carcinome ' ' :  Virchow 's  Archiv, 
XLI,  1867,  No.  XXIV,  p.  470;  ihid.,  LV,  1872,  pp.  67-159;  "Ueber  den 
Krebs":    Sammlung  klin.  Vortriige,  No.  33,  1872,  pp.  163-196. 

144 


CANCER    RESEARCH  145 

event  marked  one  of  the  final  breaks  from  the  old  belief  in  the 
humoral  nature  of  cancer.  Another  event  of  importance  was 
the  gradual  emancipation  of  investigators  from  the  idea  that 
cancer  must  of  necessity  be  due  to  an  inherited  dyscrasia  or 
''condition  of  the  blood."  The  freedom  thus  obtained  has  led 
to  the  study  of  cancer  by  innumerable  w^orkers  in  the  autopsy 
room  and  in  the  histopathological  laboratory. 

The  final  result  of  the  clash  between  dogma  and  fact  may  be 
said  to  have  resolved  itself  into  an  agreement  that  cancer  is 
local  in  its  beginning.  There  remained,  however,  a  difference 
of  opinion  as  to  whether  or  not  the  increase  in  the  size  of  the 
original  small  area  affected  is  the  consequence  of  the  communi- 
cation of  the  disease  to  adjacent  tissues.  Thus  two  sharply  op- 
posed schools  have  arisen,  holding,  respectively  (1)  that  there  is 
a  progressive  transformation  in  the  adjacent  tissues  (apposi- 
tional  transformation),  and  (2)  that  the  increase  in  the  size  of 
the  affected  area  is  due  to  the  progressive  growth  of  the  cells 
primarily  attacked  and  to  the  displacement  by  them  of  adjacent 
tissues.  This  discussion  was  pursued,  without  final  result,  up 
to  the  time  of  the  establishment  of  experimental  study  upon 
animals. 

In  the  past  twelve  years  conflicting  views  on  the  nature  of 
cancer  have  been  subjected  to  the  impersonal  arbitrament  of 
experiment.  By  this  means  a  judgment  has  been  obtained  en- 
tirely favorable  to  the  endogenous  origin  of  cancer  from  the 
tissues  with  which  it  grows  in  continuity,  and  in  which  it  has 
its  primary  site.  In  this  respect  experiment  may  be  said  to 
have  but  confirmed  conclusions  arrived  at  in  1867  by  Waldeyer, 
who,  while  generously  acknowledging  the  work  of  others  along 
the  same  lines,  concluded  that  all  primary  carcinoma  arose  by 
growth  in  continuity  from  the  covering  epithelium,  and  metas- 
tases, by  the  growth  of  fragments  transported  by  the  blood  or 
lymph  streams.  Waldeyer  extended  these  results  to  the  sar- 
comata. 

The  results  of  experiment  go  further,  however,  than  merely 
excluding  all  conclusions  other  than  that  a  malignant  new 
growth  is  part  and  parcel  of  the  body  of  its  host;  they 
permit  a  choice  to  be  made  among  many  alternative  views  con- 
cerning the  manner  in  which  cancer  is  derived  from  normal 
tissue.  These  have  been  considered  in  the  section  of  Histopath- 
ology. 

Experiments  on  mice  demonstrated  very  early  that  it  was 
necessary  to  separate  the  problem  of  the  genesis  of  malignant 
ne  vv  growths  from  that  of  the  conditions  suitable  for  growth ; 
that  is,  from  the  causes  which  determine  mere  increase  in  size 


146  THE    CANCER    PROBLEM 

and  extension  in  the  animal  primarily  affected.^  Transplanta- 
tion was  shown  to  be  essentially  similar  to  the  process  of  metas- 
tasis as  it  occurs  in  the  individual  providing  the  spontaneous 
tumor.  The  experimental  transmission  of  carcinoma  showed 
that,  while  conditions  leading  to  the  initiation  of  malignant 
tumors  were  relatively  infrequent,  once  begun,  this  cancerous 
proliferation,  under  favorable  conditions,  could  persist  for  a 
long  time  unaltered;  and  could  give  rise  to  masses  of  tissue  of 
great  size  in  a  large  proportion  of  healthy  animals,  quite  unham- 
pered by  the  restrictions  which  determine  the  growth  and  limit 
the  size  attained  by  adult  organisms." 

The  value  of  studying,  for  its  own  sake,  the  problem  of 
growth  as  presented  under  experimental  conditions  has  been 
an  incentive  to  much  investigation,  especially  by  the  workers 
of  the  Imperial  Cancer  Research  Fund,  London,  and  of  the 
Royal  Prussian  Institute  of  Experimental  Therapeutics, 
Frankfort-on-Main.^  They  have  recognized  the  value  of  the 
opportunities  afforded  by  such  study  for  obtaining  indirect 
knowledge  of  the  nature  of  cancer,  and  each  school  has  made 
guarded  inferences  as  to  etiology.  By  a  study  of  hoiu  cancer 
grows,  each  has  hoped  to  obtain  knowledge  of  why  it  grows. 
According  to  their  conceptions  the  processes  of  growth  present 
a  rational  starting  point  for  the  study  of  some  of  the  problems 
.  of  cancer,  but  Ehrlich  and  his  associates  on  the  one  hand,  and 
Bashford  and  his  coworkers  on  the  other,  have  arrived  at  di- 
vergent conclusions. 

In  the  human  subject  only  the  stage  at  which  a  tumor  has 
arrived  can  be  subjected  to  clinical  and  pathological  or  micro- 
scopical examination ;  the  stages  through  which  it  has  passed 
and  those  through  which  it  may  pass  in  future  are  necessarily 
left  to  the  imagination.  The  discussion  of  any  influence  which 
surroimding  tissues,  or  the  body  and  its  fluids  as  a  whole,  may 
exert  on  the  process,  is  equally  hypothetical.  So  far  as  the 
fully  developed  cancer-cell  permits,  these  gaps  may  be  and 
already  have  been  partially  filled  by  experiment.  Only  by 
experiment,  supported  by  knowledge  previously  acquired 
through  morbid  anatomy  and  histology,  has  it  been  possible  to 
come  to  certain  unequivocal  conclusions,  such  as  the  following: 

1  Bashford  and  Murray. — ' '  The  Significance  of  the  Geographical  Distri- 
bution of  Cancer,"  First  Annual  Report,  Imperial  Cancer  Research  Fund, 
London,  July,  1903. 

-  Bashford  and  Murray. — ' '  The  Significance  of  the  Zoological  Distribu- 
tion, the  Nature  of  the  Mitoses,  and  the  Transmissibilty  of  Cancer." 
Proc.  Roy.  Soc,  Vol.  73,  Jan.  12,  1904. 

^  Ehrlich,  P. — ' '  Experimentelle  Karzinomstudien  an  Mausen, ' '  Zeit.  f. 
Aertzl.  Forthildung,  1906,  III,  205;  ibid.,  Arbeit,  aus  dem  Kgl.  Inst,  fiir 
experimentelle  Therap.,  Hft.  1,  1906,  p.  75. 


CANCER    RESEARCH  147 

The  "Individuality"  of  Cancer  Established  by  Experiment — 

rrom  the  study  of  tumors  in  animals  spontaneously  affected,  as 
compared  with  those  in  normal  animals  which  are  the  hosts  of 
transplanted  tumors,  it  has  been  considered  proved  that  the 
tumor  is  peculiar  to  the  individual  in  which  it  arises,  contain- 
ing nothing  demonstrably  extraneous.  From  the  study  of  the 
life-history  of  tumors,  as  made  possible  by  prolonged  propaga- 
tion, the  morphological  and  biological  metamorphoses  of  which 
tumor-cells  are  capable  have  been  clearly  demonstrated.  For 
all  that  was  known  to  the  contrary,  the  undifferentiated,  "em- 
bryonic" tissue  of  a  cancer  might  have  exhibited  typical  differ- 
entiation promptly  after  transplantation  in  the  way  that  trans- 
planted embryonic  tissues  do ;  that  this  did  not  occur  in  the  case 
of  cancer  shows  that  mere  arrested  growth  of  embryonic  tissue 
is  not  a  sufficient  explanation  of  the  origin  and  nature  of  cancer. 

The  individuality  of  cancer  has  long  been  maintained,  under 
various  guises,  on  the  basis  of  deductions  drawn  from  the  his- 
tological examination  of  the  tissues  at  the  site  of  the  primary 
lesion  and  on  those  of  the  nature  of  the  secondary  or  metastatic 
formations.  It  has  also  been  as  vehemently  denied.  When 
every  consideration  is  paid  to  the  evidence  and  arguments  which 
have  been  adduced  for  or  against  the  idea  of  the  individuality 
of  cancer,  it  must  be  admitted  that  the  purely  microscopical 
findings  in  themselves  were  insufficient  for  decision  in  all  the 
points  in  question.  Although  the  advocates  of  an  extrinsic 
(parasitic)  genesis  were  never  able  to  convince  their  opponents, 
the  pathological  anatomists,  the  latter  were  also  obliged,  on 
their  part,  to  confess  that  they  did  not  absolutely  refuse  to  ad- 
mit the  possibility  of  an  extrinsic  parasitic  etiology. 

By  the  simple  process  of  inoculating  a  bit  of  cancer  tissue, 
and  by  observing  the  local  growth  and  dissemination  of  the 
same,  long  and  patient  experiment  has  ultimately  supported 
the  view  that  all  the  characteristics  of  cancer  may  be  explained 
by  consequences  emanating  from  a  small  circumscribed  area. 
For  reasons  quite  different  from,  and  independent  of,  those  ad- 
vanced by  pathological  anatomists,  investigation  of  propagated 
cancer  has  advanced  to  two  conclusions  exceeding  all  others  in 
theoretical  and  practical  importance:  A  malignant  new  growth 
arises  (1)  in  a  circumscribed  area,  and  (2)  for  reasons  par- 
ticular to  the  host  as  an  individual. 

A  portion  of  malignant  tumor,  transferred  to  another  part  of 
the  body,  is  usually  extremely  dangerous  to  the  individual. 
Transferred  to  the  body  of  another  subject,  it  is  very  rarely 
dangerous  to  the  new  host,  and  then  only  under  conditions 
which  obtain  in  experiments  upon  lower  animals. 


148  THE    CANCER    PROBLEM 

Experiment  appears  to  have  limited  the  genesis  of  cancer, 
more  strictly  than  before,  to  a  combination  of  causes  peculiar 
to  each  individual  and  perhaps  to  the  reaction  of  his  tissues 
to  extraneous  irritative  agencies,  a  susceptibility  to  which  may 
be  inherited,  as  shown  in  the  section  on  Statistical  Consid- 
erations. Experiment  likewise  indicates,  with  equal  empha- 
sis, that  no  one  case  of  cancer  has  any  direct  relation  to  an- 
other, as  is  also  pointed  out  in  the  section  on  Statistical  Con- 
siderations. 

If  this  be  true,  then  the  question  may  be  asked — Why  propa- 
gate cancer?  To  grow  cancer  indefinitely  is  simply  to  retire 
farther  and  farther  from  the  genesis  of  the  disease.  For  many 
experimenters,  propagation  is  sufficiently  justified  as  being  an 
indirect  way  of  attacking  a  problem  which  hitherto  has  defied 
all  frontal  attacks,  while  at  the  same  time,  it  is  an  objective 
method  of  studying  the  biology  of  tumor  cells. 

Leaving  out  of  consideration  those  experimental  exigencies 
which  may  be  met  only  by  having  constant  sources  of  tumor 
material,  and  leaving  for  reference  later  the  indirect  bearing 
of  the  study  of  propagation,  some  of  its  other  advantages  may 
be  noted. 

The  Possibility  of  Transference  no  Proof  of  Infectivity  of  Can- 
cer.— The  circumstances  under  which  cancer  may  be  transferred 
artificially  from  one  animal  to  another  are  now  accurately 
known.  The  strict  limitations  under  which  this  is  possible, 
even  when  the  experimental  conditions  are  most  favorable,  are 
such  that,  for  practical  purposes,  the  danger  of  natural  trans- 
ference does  not  require  consideration,  and  is  not  even  of  suffi- 
cient importance  to  merit  debate  as  an  academic  question.  It  is 
worth  while,  however,  to  endeavor  to  dispel  a  certain  amount  of 
confusion  which  prevails  among  many  who,  having  no  practical 
experience  with  reference  to  the  experimental  transmission  of 
cancer,  are  unable  to  interpret  its  significance. 

As  a  rule  the  transference  of  a  primary  cancer  is  very 
difficult,  and  must  not  be  confounded  with  the  transference  of 
a  propagated  cancer.  In  the  former  case  a  growth  is  removed 
from  its  natural  environment  and  placed  in  strange  surround- 
ings. The  cancer-cell  rarely  survives  this  procedure.  In  the 
latter  case  the  difficulties  of  the  first  procedure  have  been  arti- 
ficially surmoimted,  the  cancer-cell  is  no  longer  a  natural  one, 
but  one  adapted  to  transference,  which,  in  some  cases,  but  even 
then  by  no  means  always,  may  be  easily  performed. 

There  are  two  important  points  to  be  borne  in  mind  with 
reference  to  the  inoculation  of  cancer.  First,  should  trans- 
ference be  held  to  indicate  a  cause  of  the  great  frequency  of 


CANCER    RESEARCH  149 

cancdr,  the  reasoning  must  start  from  tlie  difficulty  of  trans- 
ferring primary  tumors,  and  not  from  the  ease  with  which  some 
artificially  propagated  tumors  may  be  transferred.  Second, 
transference  is  effected  by  the  implantation  and  continued 
growth  of  living  cancer-cells  only.  To  assume  that  such  an 
engrafting  of  cells  peculiar  to  each  species,  yet  parasitic  for 
each,  occurs  in  nature,  not  only  from  one  individual  to  another, 
but  from  one  generation  to  another  throughout  the  vertebrates, 
postulates  that  it  has  occurred  throughout  unknown  geological 
ages,  and  presupposes  also  the  existence  of  an  animate  world 
of  which  biology  knows  nothing.  A  little  reflection  at  once 
shows  the  absurdity  of  such  an  assumption.  Nevertheless,  it 
is  entertained  by  some  who  do  not  sharply  differentiate  be- 
tween infection  and  the  implantation  or  grafting  of  living  cells.^ 
According  to  their  view  the  implantation  of  cancer  from  one 
generation  of  mice  to  another  is  an  experimental  reproduction 
of  relations  existing  in  nature.  This  involves  a  grave  fallacy. 
It  is  now  universally  agreed  that  experimental  cancer  is  neither 
more  nor  less  than  the  grafting  of  the  tumor  of  an  animal  (part 
and  parcel  of  whose  body  it  was)  into  the  same  animal  or  into 
others  to  which  it  is  alien. 

Apolant "  writes  that  the  cultivation  of  a  true  tumor  of  the 
dog  has  been  performed  successfully  by  Bashford ;  that  this  ob- 
servation has  importance  because  it  proves  that  the  transplan- 
tation through  series  of  animals  is  not  peculiar  to  the  growths 
of  the  rat  and  mouse,  but  is  shared  by  the  higher  animals. 
Therefore  the  objections  raised  that  the  tumors  of  the  mouse 
and  rat  are  fundamentally  different  from  those  of  other  ani- 
mals, for  example,  the  dog  and  man,  have  no  basis  in  fact. 

The  "Limitless"  Growth  of  Cancer. — Before  the  experimental 
era  the  growth  of  cancer  was  loosely  spoken  of  as  "limitless," 
although  it  terminated  with  the  death  of  the  individual  organ- 
ism attacked.  ISTo  single  fact  of  itself  reveals  the  fundamental 
problem  so  clearly  as  does  the  continuous  growth  of  tumors 
when  transferred  from  one  animal  to  another  over  a  period  of 
time  exceeding  the  duration  of  the  lives  of  many  successive 
generations  of  animals.  It  has  been  pointed  out  that  the  enor- 
mous amount  of  growth  obtained  by  artificial  propagation  is 
a  problem  new  to  the  biology  of  vertebrates,  and  that  the  suc- 
cessive cell  generations  are  comparable  to  growth  as  seen  in 

1  Infection  signifies  the  transformation  of  normal  into  diseased  tissues 
through  the  intervention  of  micro-organisms.  The  implantation  of  cancer 
cells  does  not  effect  any  such  transformation. 

'  Apolant,  Hugo. — ' '  Die  experimentelle  Erf  orschung  der  Geschwiilste, ' ' 
Handbuch  der  pathogenen  Micro-organismen.  Herausgeben  von  Kolle  und 
Wassermann.     Bd.  Ill,  1913,  p.  176. 


150  THE    CANCER    PROBLEM 

the  continuity  of  species,  rather  than  to  that  of  individual  ani- 
mals ;  as,  for  example,  a  mouse,  a  rat,  a  guinea-pig,  a  rabbit  or 
a  dog;  these  being  the  animals  in  which  unquestionable  tumors 
have  been  or  are  at  present  being  propagated  in  different  parts 
of  the  world.  Bashford  and  j\iurray  likened  the  bulk  of  mouse 
tumor  which  they  had  produced  by  1905  to  a  mass  greater  than 
tliat  of  an  elephant,  and  in  1906  Ehrlich  calculated  that  his  ex- 
perience signitied  the  speedy  production  of  a  mass  exceeding 
that  of  the  sun. 

The  study  of  propagation,  however,  is  also  of  interest  in  it- 
self. Are  any  limits  of  time  or  amount  set  to  it,  such  as  are 
set  to  the  other  activities  of  vertebrate  organisms — for  example 
to  the  length  of  life  itself,  or  to  the  length  of  the  gestation' 
period  ?  Does  it  give  indications  of  how  it  originated  or  how 
it  is  maintained 't  Do  tumor-strains  of  different  origin,  and 
otherwise  distinguishable  at  the  outset  of  propagation,  advance 
during  their  continuation  to  a  common  type,  either  in  morpho- 
logical characters  or  in  biological  behavior,  under  the  influence 
of  a  constant  environment  ?  Is  growth  purely  vegetative,  or  is 
it  renewed  from  time  to  time  ?  Some  of  these  questions  were 
raised  many  years  ago  as  the  result  of  the  microscopical  study 
of  cancer  in  man.  Experiment  has  only  recently  replied  to 
some  of  them ;  others  have  been  answered  only  in  ambiguous 
terms. 

The  Bearing  of  the  Study  of  Propagation  upon  Other  Phases  of 
the  Cancer  Problem. — The  propagation  of  cancer  has  thrown 
light  upon  the  spontaneous  healing  of  natural  cancer  in  human 
beings.  The  study  of  this  important  phenomenon,  either  as  it 
occurs  during  propagation  or  in  primary  tumors  in  animals, 
points  to  the  primordial  moment  of  phases  in  the  life  of  the 
tumor-cells.  Propagation  has  revealed  phases  in  the  suscepti- 
bility of  the  tumor-cells  to  the  extracellular  factors  accompany- 
ing spontaneous  healing. 

The  Microscopical  Demonstration  of  the  Facts  of  Transfer- 
ring Cancer. — The  successful  inoculation  of  cancer — carcinoma 
and  sarcoma — had  already  been  made  in  rats  and  mice ;  but 
was  neglected  and  misconstrued.  It  was  therefore  reserved 
for  Jensen,  in  1902,  in  the  case  of  carcinoma  of  the  mamma  of 
the  mouse,  to  obtain  full  recognition  for  work  which  clearly 
demonstrated  true  transplantation  or  grafting.  In  the  case  of 
carcinoma  previous  work  by  Hanau  -^  and  Morau  ^  had  not  been 

1  Hanau,  A. — ' '  Erf  olgreiehe  experimentelle  Uebertragung  von  Car- 
cinom,"  Fortschr.  d.  Med.,  Berl.,  1889,  VII,  321-329. 

2  Morau,  H. — "Eeeherches  experimentales  sur  la  transmissibilit6  de  cer- 
taines  neoplasmes  (epitheliomas  cylindriques) , "  Arch,  de  Med.  exper.,  1894, 
677. 


CANCER    RESEARCH  151 

carried  out  with  such  great  attention  to  detail ;  and  in  the  case 
of  sarcoma  the  results  had  been  imperfectly  or  ambiguously  de- 
scribed, largely  owing  to  the  difficulty  of  dealing  with  sarco- 
mata as  material  for  experimental  observation.  The  experi- 
mental reproduction  of  all  the  features  of  natural  cancer  was 
completed  by  the  observations  of  Borrel  and  Haaland,  but 
mainly  it  was  the  result  of  some  years  of  study  on  the  part  of 
the  workers  of  the  Imperial  Cancer  Research  Fund.  These  in- 
vestigators demonstrated  in  1905  that  out  of  the  minute  particle 
of  tissue  inoculated  there  were  developed,  with  one  and  the 
same  tunior  strain,  not  only  a  local  tumor,  but  also  expansive 
or  benign  and  infiltrative  or  malignant  growths,  as  well  as  sec- 
ondary growths  in  internal  organs  and  the  lymphatic  glands, 
terminal  cachexia  and  death.  In  succeeding  years  the  workers 
in  this  laboratory,  notably  Haaland  and  Murray,  have  added 
all  the  details  necessary  to  complete  the  analogy  with  the  malig- 
nant new  growths  in  man. 

Propagation  Experiments  Justify  the  Surgical  Treatment  of 
Cancer. — This  experimental  reproduction  of  all  the  features  of 
the  natural  disease  has  proved  conclusively  that  growth  takes 
place,  not  by  converting  healthy  cells  into  cancer  cells,  but  in 
consequence  of  the  proliferation  of  the  cancer  cells  introduced. 
Furthermore,  it  has  established  the  fact  that  if  the  cancer  cells 
are  surgically  removed  early  enough  after  inoculation,  all  evil 
effects  are  obviated.  Thus  experiment  has  absolved  the  surgical 
treatment  of  cancer  from  the  last  vestiges  of  the  charge  that  it 
is  unjustifiable,  and  that,  at  best,  it  is  a  mere  empirical  pro- 
ceeding. This  is  perhaps  the  most  valuable  practical  result 
yielded  by  modern  cancer  research.  Surgical  removal  is  as  yet 
the  only  sure  way  in  which  an  animal  can  be  protected  against 
the  ultimate  consequences  of  inoculation  with  cancer-cells. 

The  Infectivity  of  Cancer  in  the  Light  of  Propagation  Experi- 
ments.— Modern  cancer  research  has  yielded  no  evidence  of  the 
communicability  of  the  disease  by  infection,  and  much  fresh 
evidence  that  this  is  improbable;  while  there  is  quite  definite 
proof  that  the  cause  of  the  great  frequency  of  cancer  is  not  the 
transplantation  of  cancer-cells  from  one  person  to  another. 

Bearing  upon  the  last  point,  among  many  others,  three  very 
important  facts  may  be  mentioned :  ( 1 )  The  housing  of  cancer 
animals  in  large  numbers  with  others  has  not  led  to  any  epi- 
demic. (2)  It  has  been  found  possible  to  protect  all  animals 
against  the  inoculation  of  a  tumor  from  other  animals  of  their 
own  species,  but  it  is  quite  impossible  to  protect  the  animal  in 
which  the  tumor  developed  naturally  against  reinoculation  with 
its  own  tumor.     (3)  While  it  is  possible  completely  to  protect 


152  THE    CANCER    PROBLEM 

animals  against  an  inoculation,  and  to  hold  them  continuously 
in  that  state,  nevertheless  they  may  develop  tumors  of  their 
own.  In  other  words,  the  animal  is  resistant  to  outside  agen- 
cies, namely,  the  extraneous  cancer-cell,  but  not  to  processes 
taking  place  inside  its  own  body. 

Although  all  the  foregoing  facts  are  not  disputed  in  the  par- 
ticular cases  for  which  they  have  been  described,  the  idea  that 
cancer  is  -infective  still  finds  staunch  supporters,  even  among 
experimenters  themselves ;  notably  Borrel,  of  the  Pasteur  Insti- 
tute ;  Gaylord,  of  the  New  York  State  Laboratory ;  and,  more 
recently,  Klempcrer  ^  and  C.  Lewin,  of  the  Berlin  Charite  Can- 
cer Department.  It  must  be  admitted,  however,  that  where  they 
have  sought  to  maintain  their  position,  on  the  basis  that  the 
resistance  which  may  be  experimentally  produced  against  the 
inoculation  of  cancer  is  like  the  immunity  which  may  be  in- 
duced against  infective  diseases,  and  due  to  antibodies,  their 
contention  has  completely  broken  down,  since  they  have  not 
been  able  to  adduce  satisfactory  positive  results  in  support  of 
their  claims;  Borrel,  who  originally  inclined  to  the  idea  that 
the  immunity  reactions  would  clear  up  the  nature  of  cancer — 
presumably  the  infective  nature — later  assumed  the  position 
that  these  reactions  are  all  against  the  cancer-cell,  and  not 
against  a  cancer  virus,  and  that  they  have  little  or  no  etiological 
value. 

Apparent  endemics  of  cancer  in  mice  have  been  observed  and 
explained  as  due  to  cage  infection.  Apolant,^  in  reviewing  the 
evidence,  writes :  ''In  the  first  place  the  statistical  data  regard- 
ing cancer  epidemics  and  cage  infection  are  by  no  means  gen- 
erally recognized  as  of  value.  The  occasional  observation  of 
accumulations  of  spontaneous  tumors  in  mice  and  rats  is  not 
denied ;  I  refer  only  to  the  communications  of  Borrel,  Asher, 
Thorel,  Gaylord,  Kock,  Loeb,  Haaland.  Since,  however,  simi- 
lar occurrences  have  never  been  observed  in  the  gigantic  under- 
takings of  Bashford  and  Ehrlich,  it  appears  necessary  to  avoid 
drawing  any  far-reaching  conclusions  from  the  peculiar  isolated 
observations  which  in  part  are  also  difficult  to  comprehend." 
Apolant  goes  on  to  review  some  of  the  most  important  instances 
of  "endemics,"  including  that  of  Thorel,  which  was  proved  at 
a  later  date  to  be  possibly  the  consequence  of  a  slow  develop- 
ment of  inoculated  cancer  cells ! 

Borrel,  like  Gaylord,  has  claimed  alleged  epidemics  in  labor- 

^  Klemperer,  G. — "Der  jetzigen  Stand  der  Krebsf  orschung, "  Berl.,  1912. 

'Apolant,  Hugo. — "Die  experimentelle  Erf  orschung  der  Geschwiilste, " 
Handbuch  der  pathogenen  Micro-organismen.  Herausgeben  von  KoUe  uud 
Wassermann.     1913.     Bd.  Ill,  p.  220. 


CANCER    RESEARCH  153 

atory  and  other  animals  as  evidence  of  infection.  Other  inves- 
tigators, like  Bashford  and  his  colleagues,  who  have  recorded 
the  ages  and  ancestry  of  their  own  animals  among  whom  cancer 
frequently  appeared,  declare  that  such  concurrences  are  not  epi- 
demics at  all,  but  the  natural  result  of  a  high  proportion  of 
aged  animals,  possibly  of  the  inbreeding  of  cancerous  stock  ^ 
and  of  exposure  to  certain  specific  parasites  acting  as  irritants, 
for  example,  nematodes  and  cestodes  in  mice,  or  liver  flukes  in 
cows. 

Borrel  ^  first  drew  attention  to  the  frequency  of  nematode 
infection  in  mice,  and  has  relied  upon  the  frequent  presence 
of  these  organisms  as  evidence  that  they  act  as  intermediate 
hosts  for  a  cancer  virus.  Haaland  ^  has  described  them  in  the 
connective  tissue  of  the  mamma  of  mice,  where  cancer  so  often 
arises,  and  has  explained  the  frequency  of  chronic  inflammation 
as  caused  by  their  secretions  and  excretions.  Fibiger  *  also  has 
employed  nematodes  in  feeding  experiments  with  rats,  and  in 
two  or  three  cases  carcinomata  actually  developed.  Fibiger, 
however,  did  not  incline  to  the  above  view,  but  rather  to  the 
opinion  that  the  nematode  had  acted  as  an  irritant.  In  this 
view  he  has  been  supported  by  Bashford  ^  and  others.  It  is 
remarkable  that  so  very  few  true  carcinomata  developed  in 
Fibiger's  2,000  rats. 

Thus,  while  experiment  has  yielded  no  fresh  evidence  in 
favor  of  an  infective  etiology,  it  has  not  yet  enabled  those  who 
hold  to  the  purely  cellular  view  to  rout  effectually  their  op- 
ponents. The  latter,  however,  have  been  forced  to  abandon 
the  idea  of  direct  infection,^  and  to  seek  an  explanation  in  a 
virus  conveyed  by  an  intermediate  host,  of  whose  existence, 
however,  no  direct  evidence  is  forthcoming. 

On  the  other  hand,  even  where  upholders  of  the  cellular 
views  have  admitted  that  parasites  play  a  part,  they  have  found 
no  difficulty  in  fitting  this  role  into  the  conception  that  chronic 
irritation  is  the  essential  factor.  With  the  exception  of  these 
investigators,  and  those,  like  Lazarus-Barlow,  who  seek  to  prove 
that  all  the  irritants  associated  with   cancer  are  radioactive, 

^  See  remarks  on  heredity  in  Sec.  Ill,  p.  96  et  seq. 

2  Borrell,  A. — ' '  Epithelioses  inf ectieuses  et  epithelomas, ' '  Ann.  de  1  'Inst. 
Pasteur,  1903,  XVII,  81. 

3  Haaland.— Fourth  Scientific  Eeport,  Imperial  Cancer  Eesearch  Fund, 
1911. 

*  Fibiger,  J. — "Ueber  eine  durch  Nematoden  (Spiroptera  sp.  n.)  hero- 
orgen  ufere  papillomatose  u.  karzinomatose  Geschwiilstbildung  im  magen 
der  Ratte,"  Berl.  Min.  Woch.,  1913,  p.  289;  Zeit.  f.  Krehsf.,  1913,  13,  217. 

=>  Bashford,  E.  F.— Nature,  1913. 

*  See  remarks  on  goiter  and  ' '  cancer ' '  in  trout  in  hatcheries,  Sec.  II, 
Chap.  2,  p,  55  et  seq. 


154  THE    CANCER    PROBLEM 

the  view  is  generally  held  that  the  irritants  have  no  property  in 
common  beyond  their  association  with  cancer.  Their  interven- 
tion is  not  direct,  but  mediate.  The  common  factor  lies  in  the 
prolonged  proliferation  occurring  under  chronic  irritation. 
Under  this  circumstance  of  prolonged  proliferation,  oppor- 
tunity is  given  for  cell  variations,  some  of  which  are  inimical 
to  the  rest  of  the  cellular  community  of  which  the  organism  is 
composed. 

When  we  leave  the  field  of  generalization  for  that  of  special- 
ized work  with  the  transplanted  cancer-cell  we  enter  a  region 
where  there  is  even  greater  disagreement.  Some  investigators 
hold  that  the  study  of  the  cancer-cell  can  teach  nothing,  that  a 
virus  has  started  cancerous  growth,  and  is  not,  therefore,  neces- 
sary for  its  continuation.  Others  assert  that  only  by  observing 
the  transition  from  the  normal  to  the  cancerous  cell  is  any  evi- 
dence to  be  expected.  Others  again  claim  that  the  study  of  the 
transplanted  cancer-cell  has  not  taught  anything  which  morbid 
anatomy  and  histology  have  not  already  clearly  proved.  Still 
others  have  steadfastly  held  that  in  studying  the  transplanted 
cancer-cell  they  are  but  imitating  Darwin's  study  of  the  tame 
pigeon,  with  the  application  of  his  deductions  to  animals  in  a 
state  of  nature.  The  last  school  finds  its  chief  exponents  in 
the  adherents  of  the  Imperial  Cancer  Research  Fund  of  Lon- 
don, who  reason  that  the  study  of  the  transplanted  or  "tame" 
cancer-cell  is  bound  to  reveal  some  of  its  fundamental  prop- 
erties, arguing  that  its  behavior  during  years  of  propagation 
must  offer  indications  of  what  its  possibilities  were  in  its  "wild" 
state,  for  example,  in  the  animal  in  which  it  originally  devel- 
oped. 

THEORETICAL    RESULTS 

Criticism  of  the  Value  of  Propagation. — With  regard  to  the 
value  of  the  continuous  propagation  of  the  cancer-cell  there  has 
raged  some  acrimonious  controversy,  and  it  is  only  fair  that  a 
review  of  the  criticisms  of  some  eminent  pathologists  should  be 
placed  before  the  reader. 

The  earlier  work  appeared  to  offer  many  contradictions  to 
human  pathology.  Notably,  Ehrlich's  tumors  did  not  produce 
metastases,  and  growth  was  commonly  found  to  be  expansive 
rather  than  infiltrative.  Von  Hansemann  vigorously  attacked 
all  experimental  work  as  being  based  upon  endothelioma,  and 
not  on  carcinoma.     All  these  objections  have  been  overcome. 


CANCER    RESEARCH  155 

and  von  Hansemann's  argiiments  have  been  refuted  by  Apo- 
lant,^  Bashford  and  Murray,^  and  Haaland.^ 

It  is  still  too  early  to  appraise  properly  the  share  played  by 
experiment  in  the  abandonment  of  certain  views  on  cancer,  and 
in  the  elevation  of  others  to  positions  of  prime  importance  as 
profitable  working  hypotheses.  Opinions  of  representative 
pathologists  are  divided  as  to  what  has  been  accomplished  in  the 
past,  and  as  to  what  may  be  accomplished  by  this  means  in  the 
future  toward  advancing  knowledge  of  the  nature  and  etiology 
of  cancer. 

Adami,*  an  unbiased  spectator  so  far  as  the  interpretation 
of  experiments  is  concerned,  frankly  ranks  the  evidence  de- 
rived from  experiments  with  that  obtained  from  other  sources. 
The  enlightened  outlook  sometimes  taken  is  illustrated  by 
the  following  remarks  by  Ewing:^  "No  experimental  evi- 
dence is  needed  to  show  that  a  naalignant  tumor  may  often  be 
grafted  from  one  part  of  the  animal's  own  body  to  another, 
since  the  several  recognized  modes  of  metastasis  daily  demon- 
strate this  process.  Hahn,  Cornil,  and  others  have  needlessly 
performed  inoculations  in  human  beings  without  contributing 
any  important  scientific  information,  while  to-day  such  experi- 
ments are  being  successfully  performed  on  animals  for  legiti- 
mate objects  in  many  laboratories." 

Although,  as  Ewing  says,  no  experimental  evidence  is  needed 
to  show  merely  that  a  malignant  new  growth  may  often  be 
grafted  from  one  part  of  an  animal's  body  to  another,  the  fact 
that  it  can  almost  always  be  done  experimentally  illustrates  the 
value  of  that  method  when  applied  to  elicit  exact  information 
as  to  the  relations  obtaining  between  an  animal  and  its  own 
tumor.  In  short,  such  experiments  have  valuable  bearings  on 
every  aspect  of  the  highly  important  question  as  to  whether  a 
tumor  contains  anything  foreign  to  the  individual  attacked ; 
as  well  as  on  the  part  played  in  the  inception  of  cancer  by  the 
relation  between  an  organism  and  its  tumor.  This  procedure 
is  also  valuable  in  testing  immunity  to  inoculation,   and  in 

^  Apolant,  Hugo. — ' '  Die  epithelialen  Geschwiilste  der  Mause. ' '  Arbeit, 
aus  dem  Kgl.  Inst.  f.  experiment.  Therap.  zu  Frankfurt  a.  M.,  1906-8 
(Parts   1-4),  Pt.  I,  p.   1. 

2  Bashford  and  Murray. — ' '  On  the  Genesis  of  Mouse  Tumours. ' '  Second 
Scientific  Eeport,  Imperial  Cancer  Eesearch  Fund,  1905,  No.  2,  Part  II, 
p.  15;  "Carcinoma  Mammae  in  the  Mouse,"  Lancet,  1907,  Vol.  I,  p.  798. 

3  Haaland,  M. — * '  Contribution  to  the  Study  of  the  Development  of  Sar- 
coma under  Experimental  Conditions. ' '  Third  Scientific  Eeport,  Imperial 
Cancer  Eesearch  Fund,  1908,  p.  175;  "Spontaneous  Tumours  in  Mice." 
Fourth  Scientific  Eeport,  Imperial  Cancer  Eesearch  Fund,  1911,  p.  1. 

*Adami. — "The  Principles  of  Pathology,"  Chap.  XV — The  Neoplasms, 
London,  1909. 

*  Ewing,   J. — "Cancer,"   Harvey  Lectures,   New  York,    1908. 


156  THE    CANCER    PROBLEM 

studying  dissemination.  From  the  standpoint  of  practical 
therapeutics  it  is  the  sine  qua  non  for  testing'  the  value  of  al- 
leged "cures.''  In  many  other  ways  the  implantation  of  a 
tumor  in  the  animal  in  which  it  arose  has  contributed  and 
promises  to  contribute  valuable  knowledge. 

The  eminent  German  pathologist,  Ribbert/  who  has  done  so 
much  toward  demonstratinc:  that  tumors  grow  onlv  from  their 
own  resoul'ces,  and  not  by  apposition  through  progressive  trans- 
formation of  surrounding  tissue,  is  a  hostile  critic  of  the  ex- 
perimental method.  He  says :  ''Incidentally  I  might  remark 
that  in  general  the  results  which  have  been  gained  by  extended 
experimentation  on  animals  have  been  considerably  overvalued, 
that  is,  if  it  was  hoped  to  utilize  them  in  explaining  tumor 
genesis.  Of  the  origin  of  tumors  we  have  learned  nothing  that 
we  did  not  know  before.  So  far  as  the  transplantability  of 
tumors  is  concerned  it  should  not  surprise  us  in  the  least,  only 
it  could  not  be  demonstrated  so  long  as  one  tried  to  transfer 
human  tumors  to  animals,  for  altero-transplantation  is  in  gen- 
eral unsuccessful.  Here,  however,  it  is  nothing  else  than  a 
modified  metastasis-formation." 

Those  who  are  familiar  with  the  progTCss  of  knowledge  on 
the  difference  in  reactions  obtaining  when  heterologous  or  ho- 
mologous tissues  are  inoculated  into  animals  will  be  struck  by 
such  a  gloss  of  the  reasons  as  to  why  efforts  were  ultimately  con- 
centrated upon  the  transference  of  cancer  from  one  individual 
to  another  of  the  same  species.  The  notion  that  cancer  owes  its 
inception  to  some  common  outside  cause,  led  to  all  these  at- 
tempts to  transfer  cancer  from  man  to  animals,  or  from  an  ani- 
mal of  one  species  to  an  animal  of  another  species.  It  was  the 
demonstration  of  blood  relationship,  as  developed  by  the  study 
of  hemolysins  and  precipitins  (as  used  to-day,  for  example,  to 
discover  if  the  blood  stain  found  on  a  criminal's  clothes  is  of 
animal  or  human  origin),  which  led  to  the  concentration  of  at- 
tempts to  inoculate  cancer  by  restricting  such  experiments  to 
efforts  on  animals  of  the  same  species.  Therefore  it  was  not 
left  for  Ribbert  to  designate  the  artificial  transference  of  cancer 
as  a  modified  metastasis. 

With  the  exception  of  a  few  authors,  who  have  sought  to  use 
successful  inoculation  as  proof  of  infection,  or  as  being  respon- 
sible for  the  spread  of  the  disease,  the  implantation  of  cancers 
has  always  been  recognized  as  artificial  metastasis.  However, 
Ribbert  elsewhere  confesses  that  with  the  microscope  alone  it  is 
not  easy  to  combat  the  assumption  that  a  continually  extending 
metamorphosis  of  neighboring  cells,  with  consequent  apposi- 
1  Ribbert,   Hugo.— "Das  Wesen  der  Krankheit,"  Bonn,  1909,  pp.  48-49. 


CANCER    RESEARCH  157 

tional  growth,  occurs  around  malignant  tumors.  He  says :  ^ 
"I  cannot  disperse  my  opponents  with  histological  evidence, 
be  it  ever  so  exact.  We  are  not  in  a  position  to  follow  growth 
itself,  but  are  reduced  to  the  determination  of  isolated  findings 
in  dead  material.  Their  significance  is  often  not  easily  ap- 
preciable. What  one  thinks  he  has  substantiated  is  reversed 
by  another.  It  is  just  for  this  reason  that  I  have  brought  for- 
ward theoretical  considerations  again  .  .  ."  Acknowledging 
that  solely  by  the  exposition  of  his  microscopical  findings  he 
cannot  succeed,  Kibbert  is  obliged  to  fall  back  upon  the  results 
of  recent  experiment.  This,  by  demonstrating  that  all  the  con- 
sequences of  the  local  growth  and  dissemination  of  cancer  may 
follow  on  multiplication,  from  their  own  resources,  of  a  little 
group  of  cells  implanted  into  a  new  host,  has  vindicated  the 
justice  of  much  that  Ribbert  has  so  ably  sought  to  establish. 

Ribbert  ^  refers  to  the  results  of  experiment  as  follows :  ''I 
may  perhaps  emphasize  that  investigation  of  the  growth  of 
animal  tumors,  particularly  during  transplantation,  has  led  to 
the  same  result.  This  is  of  great  significance,  since  such  im- 
portance is  ascribed  nowadays  to  these  experiments." 

''The  mention  of  experimental  investigation  impels  me,"  he 
continues,  "to  discuss  briefly  a  point  which  is  able  to  support 
the  conception  that  tumor-cells  are  not  materially  different 
from  body-cells.  In  immunizing  experiments  one  would  nat- 
urally start  from  the  assumption  that  the  origin  of  immunity 
is  a  specific  one,  in  a  similar  sense  as  with  bacteria.  However^ 
Schone,  Michaelis,  Borrel,  and  others  have  lately  stated  that 
one  can  also  immunize  with  normal  embryonal  tissue.^  From 
this  fact  it  emerges  that  one  need  not  use  the  cells  of  the  tumor 
against  which  he  wishes  to  produce  immunity;  that  thus  the 
normal  elements  already  contain  all  that  characterizes  the 
tumor-cells,  and  that  conversely  these  latter  possess  nothing 
which  is  not  present  in  the  normal  cells.  I  have  always  thought 
so,  and  pointed  out,  upon  a  previous  occasion,*  that  one  might 
succeed  in  immunizing  against  carcinoma  with  normal  epithe- 
lium, or  perhaps  with  that  of  an  atheroma." 

Whether  extension  of  a  new  growth  ever  occurs  by  apposi- 
tion, and  whether  Ribbert  is  right  in  denying  that  a  biological 
alteration  takes  place,  transforming  the  normal  cell  into  a 
cancer  cell,   are  questions  which  cannot   be   settled  by  mere 

^Eibbert — Op.  cit. 
^  Ribbert — Loc.  cit. 

^  The  First  to  immunize  with  normal  tissues  were  Bashford  and  Murray 
in  1906. 

*  Eibbert.— DewtecTi.  med.  Wocli.,  1906,  No.  42. 


158  THE    CANCER    PROBLEM 

microscopical  examination.  It  may  be  recalled  in  this  connec- 
tion, that  the  view  upheld  by  others  before  Ribbert  embodies 
one  of  the  most  important  facts  as  to  the  nature  of  cancer. 
Charles  II.  Moore/  as  long  ago  as  1865,  on  the  basis  of  his 
investigations  at  the  Middlesex  Hospital,  London,  and,  later, 
his  colleagTie,  Campbell  de  Morgan,-  held  that  cancer  arises 
in  a  circumscribed  area,  and  that  growth  or  recurrence  after 
operation  results  only  from  the  cancer  cells  confined  within  this 
area.  How  much  less  satisfactorily  this  point  is  established  by 
the  theoretical  method  of  Ribbert  than  by  the  application  of 
experiment,  must  be  evident  to  all  who  have  read  Ribbert's 
work.  Especially  is  it  unconvincing  to  those  who  have  com- 
pared its  results,  as  embodied  in  the  foregoing  quotations,  with 
the  simple  fact  of  the  experimental  reproduction  of  the  local 
and  disseminated  lesions  of  the  disease  after  the  implantation 
of  a  minute  fragment  of  tumor. 

Criticism  of  the  Value  of  Prolonged  Propagation. — So  much  for 
criticism  as  to  the  value  of  studying  the  manner  and  conse- 
quences of  transference.  When,  however,  the  possible  profit 
to  be  derived  from  studying  cancer  during  prolonged  propaga- 
tion has  come  under  criticism  its  usefulness  is  not  admitted 
even  grudgingly.  Not  only  is  it  asserted  that  it  has  taught 
nothing,  but  it  is  declared  that  it  cannot  possibly  teach  any- 
thing. Even  Orth,  who  is  a  supporter  of  the  experimental 
investigation  of  cancer,  and  who  has  acknowledged  its  value, 
fails  to  see  utility  in  studying  the  life-history  of  a  tumor  as 
prolonged  by  artificial  propagation.  ^'ISTot  the  study  of  trans- 
planted cancer,  but  only  the  production  of  the  causal  genesis 
of  cancer,"  is  Orth's  verdict  in  his  latest  available  contribu- 
tions.^ Even  where  it  appears  probable  that  cancer  has  been 
produced  experimentally,  for  example,  by  exposure  to  X-rays, 
or  by  feeding  rats  with  cockroaches  infected  with  nematodes, 
direct  attacks  have  failed  to  elucidate  the  processes  involved. 
It  has  never  been  denied  by  experimenters  that  the  study  of 
propagated  cancer  is  only  an  indirect  way  of  attacking  the  prob- 
lems upon  which  Orth  would  make  a  direct  attack ;  namely, 
through  the  relation  obtaining  between  the  reactive  prolifera- 
tion induced  by  chronic  irritation  and  the  development  of  can- 

^  Moore,  Charles  H. — '  *  The  Antecedents  of  Cancer, ' '  Brit.  Med.  Jour., 
August  12  and  26,  1865,  pp.  164  and  201,  also  p.  473. 

"  De  Morgan,  Campbell. — Discussion  on  Cancer,  Trans.  Path.  Soc.  of  Lon- 
don, Vol.   XXV,   1874,  pp.  287  and  387. 

^  Orth,  J. — * '  Ueber  die  Krebsgeschwiilst  des  Menschen, ' '  Sitzungs- 
berichte  der  Kgl.  pr.  Akademie  der  Wissenschaften,  Jan.  28,  1909,  p.  107; 
"Ueber  einige  Krebsf ragen, "  ibid.,  Dec,  1909,  p.  1225;  "Pracarcino- 
matose  Krankheiten  und  kiinstliche  Krebse, "  Zeitschr.  fiir  Krebsf  or  schung, 
Bd.  X,  1910,  p.  42. 


CANCER    RESEARCH  159 

cer.  Thus  the  study  of  propagated  cancer  is  regarded  by  some 
investigators  as  devoid  of  all  etiological  bearings,  while  others 
regard  it  as  futile  until  more  is  known  of  the  growth  of  spon- 
taneous primary  cancer.  With  regard  to  the  first  objection  it 
may  be  stated  that  the  results  of  the  study  of  propagated  cancer 
are  already  recognizable  in  many  directions.  For  example,  it 
affords  no  proof  of  a  parasitic  or  infective  etiology;  it  gives 
new  reasons  for  delimiting  the  problem  of  origin  as  one  peculiar 
to  the  individual  from  causes  which  are  not  constitutional,  but 
local ;  ^  and  it  has  defined  the  "age-incidence"  of  cancer  as  in- 
fluencing inception,  but  not  continued  growth. 

With  regard  to  the  second  objection,  it  must  be  remembered 
that  a  study  of  the  abnormal  is  often  more  practical  than  a 
study  of  the  normal,  and  that,  in  the  history  of  biological  in- 
vestigation, the  study  of  the  abnormal  has  frequently  given 
the  key  to  the  solution  of  problems  presented  by  normal  proc- 
esses. More  than  this,  after  exhaustive  and  inconclusive  in- 
vestigation of  the  normal,  resort  has  been  had  to  the  deliberate 
production  and  investigation  of  the  abnormal,  as  in  the  cases 
of  the  fertilization  of  the  ovum ;  the  elucidation  of  problems  of 
embryology,  regeneration,  differentiation ;  and  of  the  investiga- 
tion of  the  parts  played  in  heredity  by  the  cytoplasm  and 
nucleus  of  the  cell. 

The  maintenance  of  the  idea  that  only  the  production  of 
primary  cancer  at  will  can  carry  us  further  in  the  investigation 
of  the  causal  genesis  of  cancer,  is  one  presentation  of  an  atti- 
tude adopted  from  time  to  time  during  many  years  by  eminent 
morbid-anatomists.  They  have  not  succeeded,  however,  in  pro- 
ducing cancer  and  in  describing  the  process,  and  it  is  there- 
fore strange  that  they  should  not  appreciate  the  value  of  eman- 
cipation— even  if  only  for  a  time — from  the  restrictions  im- 
posed by  the  study  of  cancer  at  its  site  of  origin,  and  by  the 
material  provided  by  the  operating  theater  and  autopsies.  They 
appear  equally  inappreciative  of  the  value  of  freedom  from  the 
limitations  imposed  by  a  study  of  what  a  cancer  is  at  the  time 
it  is  found,  without  clear  evidence  of  what  stages  had  preceded 
it,  or  through  which  it  had  already  passed,  and  without  evi- 
dence of  any  kind  as  to  what  all  the  future  potentialities  of  can- 
cerous growth  might  be. 

The  experimenters  themselves,   however,  have   pointed  out 

and  had  acknowledged  from  the  first  that  they  claimed  to  do  no 

more  than  study  the  ready-made  cancer-cell  for  prolonged  pe- 

1  See  Introduction,  Fourth  Scientific  Keport,  Imperial  Cancer  Research 
Fund,  1911. 


160  THE    CANCER    PROBLEM 

riods  of  time,  under  altered  environment.  They  have  persis- 
tently correlated  their  study  of  propagated  cancer  with  the 
study  of  the  disease  as  it  develops  naturally  in  man  and  animals. 
They  have  been  studying  "the  pathology  of  the  living,"  as 
Moynihan  expresses  it,  for  man,  and  some  of  them  claim  that 
they  have  seen  the  development  of  new  tumors  from  the  mate- 
rial they  have  propagated. 

The  comparative  knowledge  acquired  has  made  it  evident 
that  the  negative  results  of  attempts  to  produce  cancer  in  ani- 
mals are  to  be  explained  by  the  fact  that  this  was  attempted, 
perhaps  quite  irrationally,  by  subjecting  the  animals  to  various 
agencies  reasonably  held  to  be  associated  with  the  development 
of  cancer  in  man.  It  early  became  evident,  for  example,  that 
chronic  irritants  having  a  relation  to  cancer  did  not  act  by 
virtue  of  a  common  factor.  Indeed,  although  to-day  it  is  known 
how  manifold  and  different  are  the  irritants  having  relation  to 
cancer  in  man  (apart  from  certain  physical  injuries  and  the 
less  definite  evidence  of  the  mediate  intervention  of  some  para- 
sites), little  is  known  of  the  extent  to  which  irritants  may  be 
responsible  for  cancer  in  animals.  However,  the  frequency  of 
cancer  on  the  surface  of  the  body  of  vertebrates  living  in  a  state 
of  nature  is  suggestive  in  this  connection.  At  the  same  time, 
the  remarkable  divergencies  in  the  liability  of  a  single  organ  to 
cancer,  for  example,  the  mamma  and  the  liver  in  mammalia, 
have  acquired  enhanced  significance,  since  they  show  that  fac- 
tors other  than  the  mere  intervention  of  irritation,  with  its  pro- 
longed sequelae,  are  operative.  Such  divergencies  in  the  inci- 
dence of  cancer  in  organs  common  to  the  mammalia  ^  point  to 
the  possible  importance  of  peculiar  idiosyncrasies  of  species, 
and,  in  so  far  as  irritants  or  parasites  play  an  intermediate 
role,  it  follows  that  those  effective  for  one  species  may  not  be 
effective  for  any  other.  Claims  have  been  made  that  cancer  has 
been  produced  experimentally  in  rats ;  for  example,  sarcoma 
at  the  root  of  the  tail  after  exposure  to  X-rays  (Clunet,  of 
Paris),  and  carcinoma  of  the  stomach  (Fibiger,  of  Copen- 
hagen). 

Sarcoma  is  at  present  a  risky  field,  owing  to  the  many  grada- 
tions to  granulomata  of  unknown  or  uncertain  etiology,  and  in 
the  Fibiger  experiments  the  remarkable  fact  that  so  few  cases 
of  carcinoma  developed  must  be  brought  into  relation  with  the 
circumstance  that  we  do  not  have  control  of  the  frequency  of 
carcinoma  of  the  stomach  for  rats  under  other  conditions,  for 
example,  such  as  the  hereditary  influence  which  has  been  proved 
to  act  in  mice. 

1  See  Zoological  Distribution,  Section  II,  Chapter  2. 


CANCER    RESEARCH  l6l 

THE  BEARING   OF   IMMUNITY   REACTIONS   AND    OF 
PROPAGATION   ON    THE   NATURE   OF   CANCER 

When  the  general  results  of  recent  research  are  left,  in 
order  to  consider  the  highly  specialized  investigations  of  the 
phenomena  of  growth  and  immunity,  it  is  difficult  to  present  a 
short  review  of  the  enormous  mass  of  literature  which  has  rap- 
idly accumulated  in  the  past  twelve  years.  An  excellent  review 
of  practically  all  that  has  been  done  has  been  made  by  Woglom,^ 
of  the  Crocker  Cancer  Fund  of  Columbia  University,  New 
York  City.  This  author,  however,  unfortunately  refrains  from 
weighing  up  the  evidence  in  favor  of  this  or  that  conclusion, 
except  in  an  all  too  short  final  chapter.  He  gives,  however,  a 
very  valuable  bibliography  and  a  most  excellent  index  to  all 
details. 

During  many  annual  visits  to  Europe  I  have  had  oppor- 
tunities of  becoming  familiar  with  the  details  of  the  investiga- 
tions of  the  Imperial  Cancer  Research  Fund  in  London,  and  of 
studying  the  painstaking  scientific  work  which  has  been  car- 
ried on  by  the  staff  of  that  institution. 

It  is  perhaps  unfortunate  that  the  adequate  investigation  of 
cancer  on  an  experimental  basis  requires  such  enormous  re- 
sources in  money,  in  men,  and  in  animal  material.  These  re- 
sources have  been  available,  in  practically  only  two  centers  in 
the  world — to  Ehrlich,  of  Frankfort-on-Main,  and  to  Bashford, 
in  London.  In  the  scope  and  magnitude  of  his  investigations 
Bashford  has  been  enabled  to  outstrip  his  teacher,  Ehrlich.  In 
all  essential  records  of  fact,  teacher  and  pupil  are  in  agreement, 
but  as  would  naturally  be  expected  from  men  who  by  nature  are 
determined  to  cut  out  paths  of  their  own  in  any  wilderness, 
even  that  of  cancer,  there  are  divergencies  of  interpretation  ta 
which  reference  will  be  made. 

In  view,  therefore,  of  the  unique  and  extensive  experience 
of  Bashford,  who,  as  the  Director  of  the  Imperial  Cancer  Re- 
search Fund,  has  had  at  his  disposal  a  material  greater  than 
that  commanded  by  any  other  investigator,  it  has  seemed  expe- 
dient, for  the  details  of  the  particular  subject  now  under  dis- 
cussion, to  rely  mainly  upon  the  summaries  which  he  formu- 
lated for  the  International  Medical  Congress  held  in  London 
in  1913,  more  especially  since  they  met  with  no  criticism  in- 
validating any  single  statement  of  fact.  In  other  paragraphs 
the  divergencies  of  these  views  from  those  of  Ehrlich  will  be 

^Woglom,  W.  H. — "The  Study  of  Experimental  Cancer,"  Columbia 
University  Press,  1913. 


162  THE    CANCER    PROBLEM 

summarized  ou  the  basis  of  the  hitest  publication  from  his  In- 
stitute. The  text  has  been  paraphrased  in  order  to  avoid  techni- 
calities which  are  not  commensurate  with  the  scope  of  the  pres- 
ent volume.  The  reader  who  is  interested  will  find  them  de- 
scribed in  detail,  and  well  indexed,  in  Woglom's  excellent  mono- 
graph and  in  Apolant's  article  in  the  well-known  encyclopedia 
of  Kolle  and  Wassermann. 

The  Constancy  and  Variability  of  Tumor  Cells. — In  no  labora- 
tory has  the  propagation  of  cancer  been  undertaken  upon  the 
scale  adopted  at  the  Imperial  Cancer  Research  Fund,  where  as 
many  as  8G  mouse-tumors  of  different  primary  origin  were  kept 
in  propagation  for  a  long  time  for  the  purpose  of  studying  their 
relative  constancy  and  variability.  In  many  cases  these  tumors 
were  growing  also  in  several  parallel  sub-strains.  This  enor- 
mous material  has  given  unrivaled  opportunities  for  the  com- 
parative study  of  the  biology  of  the  tumor-cells  of  the  mouse. 
In  addition,  tumors  of  the  rat,  rabbit,  guinea-pig  and  dog  (for 
three  generations  only)  have  been  successfully  cultivated  for 
the  sake  of  the  general  application  of  the  facts  to  mammalia  in 
general.  Ehrlich's  is  the  only  other  institution  which  has  kept 
going  a  large  number  of  strains  restricted  to  the  mouse  and 
rat.  At  one  time  Ehrlich  had  as  many  as  10  strains  of  mouse 
tumors  of  different  origin.  These,  however,  were  only  a  frac- 
tion of  the  number  grown  in  London,  and  they  had  not  the 
greatly  varied  character  found  in  Bashford's  laboratory. 
Therefore,  while  permitting  of  some  conclusions  of  great  im- 
portance, Ehrlich's  views  have  met  with  contradiction  from 
other  laboratories.  On  the  basis  of  the  experience  of  the  Im- 
perial Cancer  Research  workers  they  have  been  found  to  be  sub- 
ject to  limitations,  and  some  of  the  essential  facts  observed  by 
Ehrlich  have  been  shown  to  be  capable  of  other  and  more  valid 
interpretations. 

Constancy  and  Variability  of  Histological  Structures. — Evi- 
dence of  the  tenacity  with  which  the  same  structure  may  be 
retained  is  furnished  by  a  tumor  which,  after  eight  years  and 
71  sub-transplantations,  retained  in  two  separate  strains  the 
structure  of  the  original  primary  growth,  namely,  a  papillifer- 
ous  adenoma.  Two  other  tumors  of  similar  structure,  after 
growing  for  seven  and  five  years  respectively,  still  retained  the 
original  structure.  On  the  other  hand,  a  fourth  tumor,  which 
in  earlier  transplantations  was  very  gland-like,  presented  later 
a  solid  structure.  Other  tumors  exhibiting  a  solid  structure  at 
the  beginning  of  propagation,  continued  to  do  so. 

One  particular  tumor,  which  caused  the  development  of  sar- 
coma (see  below),  because  of  the  extreme  variability  which  it 


CANCER    RESEARCH  163 

showed  was  propagated  for  about  three  years  in  as  many  as  17 
separate  parallel  series.  Later  seven  of  these  parallel  series 
were  maintained  in  growth  for  another  two  years.  The  struc- 
ture of  the  several  carcinomatous  and  sarcomatous  strains,  al- 
though differing  markedly  one  from  another,  yet  remained  quite 
constant  in  each  strain:  (a)  alveolar  carcinoma;  (b)  three 
strains  of  adenocarcinoma;  (c)  one  strain  of  carcinoma  with 
spindle-shaped  cells;  (d)  polymorphous-celled  sarcoma;  and 
(e)  spindle-celled  sarcoma. 

Six  tumors  were  propagated  which  showed  keratinization  as 
the  typical  differentiation  of  the  primary  growth.  Two  of 
them  continued  to  produce  typical  squamous  epithelium  after 
two  and  three  years'  growth,  and  31  and  33  transplantations, 
respectively.  A  third,  in  which  keratinization  was  combined 
with  the  formation  of  sebaceous  material,  continued  to  do  so 
after  three  years  and  27  sub-transplantations.  The  other  three 
completely  lost  the  power  of  keratinization  after  varying  lengths 
of  propagation. 

Of  tumors  showing  sebaceous  differentiation,  two  maintained 
this  character  in  full,  one  for  four  years,  during  29  sub-trans- 
plantations. The  third  showed  sebaceous  differentiation  regu- 
larly for  the  first  30  transplantations.  In  the  succeeding  six 
transplantations  this  change  was  usually  absent,  and  when 
present  was  only  small  in  amount,  the  tendency  to  sebaceous 
differentiation  apparently  disappearing  completely.  The  fourth 
showed  sebaceous  material  and  keratin  in  the  original  primary 
tumor.  The  keratin  continued  in  one  strain  for  seven  trans- 
plantations, then  disappeared,  to  reappear  again  slightly  from 
the  nineteenth  to  the  twenty-fifth  transplantation.  In  the 
fortieth  transplantation  it  was  found  that  the  vacuoles  con- 
tained, not  sebaceous  material,  but  glycogen.  This  must  have 
been  going  on  for  some  time,  the  glycogen  being  mistaken  for  j 
fat.  Another  strain  showed  keratin  and  a  small  amount  of 
sebaceous  material  continuously  for  20  transplantations,  when 
both  were  lost  and  had  not  reappeared  throughout  another  20 
transplantations. 

Relatively  enormous  quantities  of  glycogen  continued  to  be 
formed  by  a  tumor  which  was  propagated  for  five  and  one-half 
years.  On  the  other  hand,  a  tumor  which  showed  considerable 
amounts  of  glycogen  in  the  earlier  transplantations  did  not 
fully  retain  this  character.  The  glycogen  became  gradually  less 
in  amount  during  six  transplantations,  and  almost  disappeared. 
Constancy  and  Variability  of  More  Subtle  Properties.^ — While 
keratin,  glycogen,  and  fat  formation  are  biochemical  activities 
of  the  cancer-cell  capable   of  microscopical   study,   there   are 


164  THE    CANCER    PROBLEM 

others  which  cannot  yet  be  made  evident  to  the  eye,  except  in 
their  consequences.  Such  are,  particuhirly  (1)  the  power  pos- 
sessed by  some  rare  carcinomata  of  producing-  sarcoma  in  the 
connective  tissue  of  healthy  mice,  and  (2  )  the  conditions  known 
as  imnnmity  reactions,  referred  to  below. 

Sarcoma  Development.- — The  remarkable  phenomenon  was  first 
described  by  Ehrlich  and  Apolant.^  The  process  has  since 
been  observed  in  other  laboratories.  It  consists  essentially  in  a 
transformation  of  the  stroma  into  sarcoma  because  of  some 
hitherto  undefined  influence  proceeding  from  the  carcinoma 
cells.  Ehrlich  and  Apolant  assumed  that  the  end  of  all  carci- 
nomatous tumors  during  propagation  would  be  their  replace- 
ment by  sarcoma.  Therefore  the  loss  of  power  to  induce  sar- 
coma is  of  great  theoretical  interest. 

The  loss  of  the  power  to  eff'ect  a  sarcomatous  transformation 
of  the  connective  tissues  occurred  in  five  carcinomatous  sub- 
strains derived  from  a  strain  which  called  forth  sarcoma  devel- 
opment irregularly,  and  its  appearance  was  promoted  rather 
than  hindered  by  rapid  repetition  of  the  transplantations.  An- 
other tumor  caused  the  development  of  sarcoma  in  practically 
every  animal,  from  the  twelfth  to  the  twenty-fifth  transplanta- 
tion, in  all  the  sub-strains  propagated,  if  the  tumor  was  per- 
mitted to  grow  for  about  two  months ;  but  remained  pure  carci- 
noma if  transplanted  at  intervals  of  a  month  or  less.  Four  car- 
cinomatous sub-strains  which  were  kept  growing  presented 
variations  from  this  behavior. 

In  the  first  sub-strain  the  variation  was  in  the  direction  of 
an  earlier  appearance  of  the  sarcoma.  This  occurred  after  the 
twenty-fifth,  and  continued  during  the  next  twenty  transplanta- 
tions, until,  finally,  the  early  onset  of  sarcoma  development, 
combined  with  slow  growth  of  the  carcinoma  proper,  rendered 
it  impossible  to  retain  the  carcinoma  in  propagation,  and  the 
strain  became  pure  sarcoma.  In  the  second  sub-strain  the 
change  began  to  appear  at  a  later  period,  occurring  only  after 
one  hundred  days  or  more,  instead  of  after  sixty  days.  Subse- 
quently, even  after  two  hundred  days,  the  tumors  remained 
pure  carcinoma.  This  condition  continued  during  fourteen 
transplantations,  or  fifteen  months,  and  the  power  of  producing 
sarcoma  was  ultimately  lost.  Sub-strains  3  and  4  began  by 
causing  sarcoma  about  the  sixtieth  or  seventieth  day,  continu- 
ing to  do  so  up  to  the  fifty-third  transplantation,  but  thereafter 
the  appearance  of  sarcoma  was  delayed,  so  that  the  complete 
loss  of  this  power  seemed  probable. 

^  Ehrlich  and  Apolant. — ' '  Beobachtungen  iiber  maligne  mausetumoren, ' ' 
Berl.  Jclin.  Woch.,   1905,   28,  871. 


CANCER    RESEARCH  165 

The  power  to  induce  sarcoma  development  is  characteristic 
of  only  a  small  minority  of  transplantable  tumors.  When  it 
occurs  it  is  almost  certain  that  it  is  a  characteristic  of  the  pri- 
mary tumor.  The  same  phenomena  have  been  observed  in 
transplantations  of  spontaneous  tumors  into  the  mice  from 
which  the  primary  tumors  were  obtained.  This  condition  has 
also  been  demonstrated  in  man. 

At  the  Eockefeller  Institute  growths  in  the  fowl  have  been 
discovered  which,  imder  the  microscope,  it  is  impossible  to  dis- 
tinguish from  sarcoma,  and  which  are  transmissible  by  means 
of  a  virus  contained  in  a  cell-free  filtrate  obtained  through  a 
porcelain  filter  and  by  a  dried  powder.  Cell-free  filtrates  pre- 
pared from  carcinomatous  tumor,  and  tumor  of  mixed  carci- 
nomatous and  sarcomatous  structure,  as  well  as  pure  sarcoma  of 
the  mouse,  did  not  lead  to  tumor  formation  after  inoculation. 
It  has  been  impossible,  therefore,  to  separate  the  property  of 
producing  sarcoma  from  the  vital  activity  of  mouse  tumor  cells. 
The  same  negative  results  followed  the  inoculation  of  these 
tumors  when  dried  in  vacuo.  The  differences  between  the  "sar- 
coma" of  the  fowl  and  the  mouse  in  these  respects  are  not  fully 
cleared  up,  and  the  sarcomatous  nature  of  the  fowl  tumor  is 
received  with  skepticism  by  some  authorities.  The  nature  of 
this  activity  of  some  mouse  carcinomata  is  still  as  obscure  as 
that  of  the  origin  of  malignant  new  growths  in  general.  The 
attempt  to  explain  sarcoma  development  by  the  transference  of 
a  virus  from  the  carcinoma  cell  to  the  connective  tissue  is  unsat- 
isfactory, since  it  will  not  explain  the  subsequent  loss  of  this 
property  and  at  the  same  time  the  continued  growth  of  the 
carcinoma  cells. 

The  Immunity  Reactions.- — The  employment  of  the  term  "im- 
munity" with  reference  to  cancer  signifies  nothing  more  than 
the  exemption  of  the  individual — under  clearly  defined  circum- 
stances— from  the  consequences  of  transplanting  a  tumor  from 
another  individual  of  the  same  species. 

Resistance  to  the  transplantation  of  cancer  includes  a  large 
number  of  phenomena  which  are  of  the  nature  of  hindrances 
to  the  continued  growth  of  the  already  fully  developed  cancer- 
cell.  The  analysis  of  these  phenomena  has  permitted  the  dis- 
covery of  some  subtle  properties  of  the  cancer-cell,  as  well  as 
of  some  of  the  relations  existing  between  it  and  the  animal  in 
which  it  grows,  both  in  the  case  of  the  natural  and  in  that  of 
the  transplanted  cancer-cell. 

Artificially  induced  resistance  to  the  continued  growth  of 
grafts  does  not  create  any  exemption  from  the  liability  to  the 
development  of  cancer.    It  is  certain,  too,  that  cancer  is  rarely, 


166  THE    CANCER    PROBLEM 

if  ever,  communicated  naturally  or  spontaneously  from  one 
individual  to  another  by  transplantation,  and  that  its  great 
frequency  cannot  be  explained  in  this  way.  Therefore  the 
mechanism  of  its  natural  development  differs  fundamentally 
from  transplantation,  and  the  use  of  the  term  "immunity"  may 
be  justified  only  by  convenience. 

The  study  of  such  artificial  resistance,  however,  has  thro^vn 
light  upon  the  nature  of  the  tumor-cells  and  their  relation  to  the 
individual  serving  as  food  purveyor.  But  sharp  distinctions 
must  be  drawn  between  heterologous,  homologous,  and  autol- 
ogous ^  inoculations,  whether  employed  for  the  purpose  of 
inducing  or  of  testing  resistance. 

Resistance  to  Heterologous  Inoculation.. — Heterologous  inocu- 
lation may  be  practiced  in  two  ways.  One  species  of  animal, 
say  a  rat,  may  be  inoculated  with  the  tumor  of  another  animal, 
say  a  mouse,  and  the  rat  may  then  be  tested  as  to  resistance  to 
an  inoculation  of  its  own  kind  of  tumor,  or  for  resistance  to 
mouse  tumor.  In  the  first  instance  no  resistance  is  induced ; 
in  the  second  there  is. 

There  is  general  agreement  that  the  normal  tissue  of  tumors 
of  one  species  of  animal  is  incapable  of  progressive  growth, 
or  even  of  continued  existence,  in  another  species.  Very  ex- 
tensive investigations  have  been  made  into  this  subject,  and  the 
few  positive  results  cannot  be  set  up  against  the  enormous  pre- 
ponderance of  negative  results  obtained.  By  far  the  greater 
mass  of  accumulated  data  shows  that  tumors  of  one  species  are 
incapable  both  of  progressive  growth  in  another  species  and  of 
power  to  induce  resistance  to  tumors  of  the  species  inoculated. 
These  two  lines  of  inquiry,  therefore,  agree  in  bringing  out 
general  exemptions  which  can  be  explained  only  on  the  basis 
that  tumors  have  a  specificity  analogous  to  that  distinguishing 
the  organisms  from  one  another  as  zoological  species.  Of  them- 
selves these  two  groups  of  phenomena  have  no  bearing  upon  the 
resistance  which  may  be  induced  against  the  inoculation  of 
tumors  into  other  individuals  of  the  same  species.  In  conjunc- 
tion with  other  studies  they  do  have  a  bearing  upon  the  ques- 
tion of  whether  an  immunity  is  induced  analogous  to  that 
against  infective  diseases,  by  showing  that,  when  induced,  it 
does  not  depend  on  a  virus  common  to  cancer  in  whatever 
species  of  animal  it  occurs. 

Induced  resistance  to  a  repetition  of  the  heterologous  inocu- 

1  Heterologous  inoculation  ^  from  one  species  to  another. 
Homologous  "  =  from  one  animal  into  another  of  the  same 

species. 
Autologous  "  ^  reinoculation  into  the  same  individual. 


CANCER    RESEARCH  167 

lation  has  been  demonstrated  to  occur  and  to  give  reactions 
identical  in  nature^  both  in  vivo  and  in  vitro,  to  the  well  known 
hemolytic  and  cytotoxic  reactions  induced  by  immunizing  with 
antigens  from  strange  species.  It  is  possible  that  the  tumors 
and  tissues  of  nearly  related  species — for  example,  the  blood 
of  the  rat  and  of  the  mouse — do  have  a  slight  reciprocal  influ- 
ence ;  but,  if  so,  its  existence  only  serves  to  emphasize  the  im- 
portance of  blood-relationship  rather  than  the  intervention  of  a 
cancer  parasite  common  to  the  different  zoological  species. 

The  tissues  need  not  be  alive  m  order  to  induce  the  hemolytic, 
cytolytic,  and  heterologous  cancer  immune  reactions,  but  retain 
this  power,  for  example,  after  mechanical  disintegration. 

Heterologous  Immune  Sera.  — One  of  the  hopes  awakened  by 
the  knowledge  of  the  cytotoxins  was  that  of  a  further  develop- 
ment of  a  rational  organotherapy.  In  the  promotion  of  more 
accurate  diagnosis,  and  in  forensic  medicine,  the  methods  relied 
on  have  yielded  advances  of  prime  importance ;  but  the  hope  of 
fresh  therapeutic  triumphs  has  not  been  fulfilled.  The  sharp 
specific  distinctions  which  at  times  may  be  drawn  in  vitro  be- 
tween normal  and  cancer-immune  sera  do  not  necessarily  obtain 
also  in  vivo.  In  the  test-tube  they  present,  in  varying  degree, 
hemolytic  precipitin  and  cytolytic  reactions  which  as  yet  have 
not  been  shown  to  have  any  distinctive  characters.  '^Cancer- 
immune"  sera  must  to-day  be  regarded  as  devoid  of  all  action 
in  the  living  body.  As  vehicles  for  the  communication  of  pas- 
sive immunity,  such  heterologous  sera  have  proved  valueless, 
and  likewise  they  have  not  been  demonstrated  to  possess  quali- 
ties which  may  be  relied  upon  for  purposes  of  diagnosis. 

Under  this  category  it  is  convenient  to  refer  to  the  results 
which  have  been  interpreted  as  toxic  or  anaphylactic  phenom- 
ena following  a  repetition  of  an  inoculation.  On  the  basis  of 
careful  and  numerous  repetitions  of  the  method  on  which  such 
observations  have  been  advanced,  the  conclusion  has  been 
reached  that  they  are  due,  not  to  anything  specific  to  cancer  tis- 
sue, but  rather  to  accidental  bacterial  contamination. 

Homologous  Immunization  and  Resistance.- — Homologous  re- 
sistance may  be  considered  from  the  standpoint  of  whether  it 
is  preexistent  and  natural  or  induced  by  active  changes  follow- 
ing various  procedures. 

Natural  Resistance. — Natural  resistance  played  a  much  more 
prominent  part  at  the  beginning  of  the  investigation  of  im- 
munity to  cancer  than  it  does  to-day.  During  the  period  when 
an  appropriate  technic  was  being  developed,  many  observations 
could  not  be  otherwise  than  tentative.  For  example,  with  one 
form  of  technic  the  primary  transplantation  of  certain  hemor- 


168  THE    CANCER    PROBLEM 

rhagic  mammarv  growths  of  mice  succeeded  not  more  than  once 
in  500  attempts.  With  a  different  technic  these  growths  were 
as  easy  to  trausphmt  as  other  manmiary  tumors.  Naturally  the 
appearance  of  499  resistant  mice  out  of  500  was  calculated  to 
give  great  importance  to  natural  resistance.  The  real  explana- 
tion, however,  was  found  in  the  employment  of  such  large  doses 
for  inoculation  that  auto-immunization  was  induced  and  growth 
stopped.  ,  Perhaps  also  the  greater  suitability  for  growth  of 
young  than  of  old  mice  was  not  fully  recognized  at  that  time. 
The  existence  of  a  certain  amount  of  natural  variability  in 
power  of  reaction  in  different  animals  cannot  be  denied,  and 
account  must  also  be  taken  of  age,  site,  dose,  and  time  interval. 
Although  some  tumor-strains  are  relatively  indifferent  to  age, 
no  strain  has  been  found  which  grows  better  in  old  than  in 
young  animals.  Young  animals,  as  a  rule,  are  more  susceptible 
than  old  ones,  w^hether  they  come  of  normal  or  of  cancerous 
stock,  the  latter  not  offering  a  more  favorable  soil. 

Since  young  animals  are  more  suitable  for  inoculation  and 
continued  growi:h  than  old  animals,  the  rarity  of  cancer  in  the 
young  is  not  due  to  constitutional  resistance  to  growth,  and  its 
frequency  in  the  old  is  not  due  to  a  constitutional  change, 
occurring  with  senescence,  favorable  to  the  growth  of  cancer  in 
general.  This  conclusion  suggested  experiments  to  determine 
whether  animals  naturally  suffering  from  the  disease  offered  a 
more  suitable  soil  than  others  for  the  growth  of  cancer  in  gen- 
eral. It  was  found  that  they  did  not  do  so.  Whereas  the  re- 
inoculation  of  an  animal  with  its  own  tumor  is  almost  always 
successful,  the  success  of  the  primary  transplantation  on  in- 
oculating other  cancer-animals  is  on  a  level  with  that  for  normal 
animals.  The  strict  individuality  of  spontaneous  tumors  has 
been  demonstrated  by  the  resistance  which  the  majority  of 
strange  hosts  offer  to  the  introduced  cancer-cell,  and  by  the 
fact  that  it  is  impossible  to  immunize  a  mouse  against  an  in- 
oculation of  its  own  tumor. 

Active  Resistance  Induced  by  Tumors. — Active  resistance  may 
be  induced  in  a  variety  of  ways — by  inoculating  with  spontane- 
ous or  propagated  tumor  without  obvious  growth  following;  by 
inoculation  with  propagated  tumors  w^hich,  after  a  considerable 
amount  of  transitory  growth,  become  absorbed;  or  by  inoculat- 
ing with  normal  tissues. 

If  the  dose  of  spontaneous  tumor  inoculated  without  giving 
rise  to  daughter-tumors  in  normal  mice  has  been  sufficiently 
large,  they  will  exhibit  resistance  to  a  second  inoculation  of  a 
propagated  tumor  which  takes  in  maximum  percentage  and  pos- 
sesses extreme  power  of  grow^th.    The  extent  of  the  resistance  is 


CANCER    RESEARCH  169 

not  uniform  for  all  such  negative  inoculations  with  spontaneous 
or  propagated  tumors.  If  the  dose  be  too  small  resistance  may 
be  practically  absent,  and  the  animals  may  react  almost  nor- 
mally by  giving  a  number  of  tumors  approximating  to  the  con- 
trol. Conversely,  the  dose  used  to  test  the  existence  of  resist- 
ance, if  present,  may  be  so  large  as  to  overcome  it.  Spontaneous 
tumors  also  vary  among  themselves  in  the  extent  to  v^rhich  they 
induce  resistance  against  the  same  test  tumor-strain. 

Propagated  tumors  exhibiting  the  phenomenon  of  transitory 
growth  followed  by  spontaneous  healing,  induce  resistance  to  re- 
inoculation  whenever  this  results.  This  resistance  is  usually 
absolute  for  a  secondary  inoculation  of  the  same  tumor-strain, 
but  may  be  only  partial  or  altogether  absent  in  the  case  of  dif- 
ferent tumor-strains.  There  is,  thus,  a  degree  of  resistance 
common  to  all  tumors. 

Active  Resistance  Induced  by  Normal  Tissue. — ISTormal  tis- 
sues— defibrinated  blood,  erythrocytes,  liver,  spleen,  testis, 
mammary  gland,  kidney,  placenta  (freed  from  blood),  entire 
embryos,  embryonic  skin,  etc. — induce  a  high  degree  of  resis- 
tance. The  most  convenient  tissues  with  which  to  work  are 
blood  and  embryonic  skin.  The  latter  is  especially  suitable,  be- 
cause of  the  great  uniformity  that  may  be  obtained,  both  tech- 
nically and  in  the  results,  and  because  it  is  also  the  most 
potent.  Spleen,  while  giving  a  high  degree  of  resistance,  is  apt 
to  be  infected.  Liver  is  also  liable  to  be  infected,  and  is  not  so 
good  an  immunizing  agent.  Serum  and  plasma  do  not  induce 
any  resistance.  The  dosage  of  normal  tissues  can  be  more 
accurately  adjusted  because  of  the  uniformity  of  the  material 
and  of  the  amount  of  growth  exhibited  on  transplantation — a 
variable  factor  which  may  be  excluded  in  the  case  of  blood. 

The  power  to  induce  resistance  varies  from  one  tissue  to  an- 
other, and  the  same  tissue  does  not  induce  the  same  degree  of 
resistance  against  all  tumor-strains.  The  blood  produces  a 
high  degree  of  resistance  against  one  strain,  but  not  against 
others.  Embryonic  skin  was  found  to  produce  the  highest  de- 
gree of  resistance  against  a  squamous-celled  carcinoma.  This 
gave  rise  to  the  surmise  that  histological  relationship  might 
have  some  specific  influence,  although  the  possible  influence  of 
a  high  and  pure  dose  of  epithelium  could  not  be  excluded. 
Further  experience  has  not  yet  tended  to  confirm  this  view  as 
to  histological  relationship,  and  the  results  may  be  explicable 
rather  by  the  varying  qualities  of  the  tumor-strains,  rendering 
some  more  susceptible  to  resistance,  as  described  below. 

The  high  degree  of  resistance  induced  by  spleen  is  remark- 
able, and  has  attracted  particular  attention,  owing  to  the  ap- 


170 


THE    CANCER    PROBLEM 


parent  rarity  of  metastases  in  this  organ.     Testis  was  stated 
not  to  produce  resistance,  but  lias  also  been  found  to  do  so. 

The  Parallel  in  the  Onset,  Duration,  and  Distribution  of  the 
Resistance  Induced  by  Tumor  and  Normal  Tissue. — After  an 
immunizing  inoculation  the  parallel  in  the  rise,  duration,  and 
disappearance  of  immunity  induced  by  normal  and  tumor  tis- 
sue, as  sho^vn  in  the  accompanying  curve  (Fig.  1),  is  of  great 


JS"  3>aY# 


t,TnJiTyp  mkin—^.  I  oTTi  on._..  Lonlro  Ift 

FxG.  1. — *Curves  showing  the  extent  and  duration  of  the  resistance  induced 
in  mice  with  embryo  mouse  skin  and  spontaneous  adenocarcinomata  of  the 
mammary  gland  of  the  mouse,  respectively.  The  percentage  of  immune 
animals  is  depicted  on  the  vertical,  the  duration  of  immunity  on  the 
horizontal. 

importance.     Of  normal  tissues  skin  always  induces  a  higher, 

and  kidney  a  lower  level  of  resistance  than  does  spontaneous 

tumor.     There  is  throughout,  however,  a  parallel  course  for  all 

three  curves,  the  maximum  being  attained  at  about  ten  days, 

with  a  return  to  the  nomial  level  after  about  eighty  days.     This 

parallel  of  itself  would  serve  as  evidence  that  resistance  is 

identical  in  nature,  whether  induced  by  normal  or  cancer  tissue. 

An  extraneous  agent  or  virus  cannot  be  made  responsible  for 

the  resistance  induced  by  embryonic  skin,  and  there  seems  no 

*  From  Woglom,  in  Journal  of  Experimental  Medicine,  Vol.  XVI,  No.  5, 
1912. 


CANCER    RESEARCH  171 

reason  to  suppose  that  the  resistance  induced  by  cancer  tissue 
is  due  to  any  property  other  than  that  of  cancer  qua  mouse 
tissue. 

The  resistance  conferred  by  an  immunizing  inoculation  is 
distributed  all  over  the  subcutaneous  tissues  of  the  body,  the 
peritoneum,  and  the  internal  organs  (kidney),  extending  even 
to  the  blood.  If  a  tumor-strain  naturally  giving  rise  to  metas- 
tases be  injected  as  fine  emulsion  into  the  tail  vein,  metastases 
in  the  lungs  can  be  stimulated,  but  in  immunized  animals  the 
number  falls  far  behind  that  of  the  control.  The  wide  dis- 
tribution of  resistance  throughout  the  body  almost  makes  the 
assumption  of  the  presence  of  some  substance  in  the  body-fluida 
a  necessary  postulate,  and  the  indications  of  quantitative  rela- 
tions point  in  the  same  direction. 

Distinction  Between  Living  and  Dead  Tissues. — Both  tumor 
and  normal  tissue  must  be  alive  in  order  to  call  forth  resistance. 
If  killed,  or  disintegrated  so  that  no  intact  cells  remain,  no 
resistance  is  induced.  This  applies  whether  the  means  em- 
ployed be  chemical,  mechanical  (as  effective  crushing  at  or 
below  0°  C),  or  actinic  (as  heat  or  exposure  to  radium).  The 
absence  of  immunizing  effect  cannot  be  overcome  by  enormously 
increasing  the  dose.  Even  red  blood  corpuscles,  if  completely 
ground  at  the  temperature  of  ice  and  salt,  lose  all  power  to 
induce  resistance.  It  would  appear  that  growth  following  in- 
oculation must  contribute  to  the  production  of  resistance  by 
actually  increasing  the  dose  of  the  effective  substances;  yet 
mere  growth  of  itself  seems  to  be  non-essential,  since  growth  of 
the  inoculated  red  blood  corpuscles  may  certainly  be  excluded. 
Some  subtle  product  of  metabolism  of  the  living  cell,  in  conse- 
quence of  whose  action  a  change  is  effected  in  the  body-fluids 
of  the  resistant  animal,  appears  to  be  essential. 

Homologous  Immune  Serum.^ — The  serum  of  immunized  ani- 
mals has  not  yet  been  shown  in  in  vitro  experiments  to  differ 
from  that  of  normal  mice,  nothing  of  an  antitoxic  or  cytolytic 
reaction  having  been  discovered.  Neither  has  it  been  shown  to 
possess  curative  powers,  nor  has  passive  resistance  been  con- 
ferred by  its  means.  The  milk  of  highly  immune  mothers  con- 
veys no  resistance  to  their  offspring. 

Nature  of  the  Change.- — The  nature  of  the  change  effected  by 
immunizing  has  been  elucidated  in  part  by  studying  the  proc- 
esses of  the  spontaneous  healing  of  tumors;  by  examining  the 
site  of  grafting  in  normal  and  in  immune  animals ;  by  searching 
for  histological  evidences  of  reaction  throughout  the  body;  by 
analyzing  the  results  of  double  inoculations  of  different  tumor- 
strains;  by  observing  the  effects  of  the  progressive  and  trail- 


172  THE    CANCER    PROBLEM 

sitory  growth  of  tumors  on  the  rohitive  weights  of  the  sovpral 
organs  of  the  body  ;  and,  histlj,  by  observing  any  changes  which 
may  occur  in  the  metabolism. 

Spontaneous  Healing.^ — The  phenomenon  of  spontaneous  heal- 
ing may  bo  obtained  with  any  desired  freipiency  from  a  suffi- 
ciently representative  series  of  different  propagated  tumor- 
strains.  It  is  extremely  rare,  however,  in  spontaneous  growths, 
not  occurring  as  often  as  once  in  every  hundred  of  the  spon- 
taneous tumors  observed. 

Very  characteristic  histological  pictures  of  tumors  under- 
going absorption,  after  growing  for  a  time,  and  perhaps  attain- 
ing huge  dimensions,  have  been  described  by  Bashford  and 
^Furray,  Cramer,  and  Gaylord.  There  are  hemorrhages;  the 
tumor-cells  vary  in  their  staining  capacity,  exhibiting  light  and 
dark  areas,  or  they  are  more  obviously  degenerating;  aggrega- 
tions of  plasma-cells  are  more  frequent  than  in  growing  tumors ; 
later  the  tumor-cells  are  cut  up  into  groups  surrounded  by  a 
large  zone  of  phagocytes,  and  ultimately  scar-tissue  forms. 

The  conditions  obtaining  between  the  connective  tissue  and 
the  cancer-cells  are  obviously  quite  the  opposite  of  those  exist- 
ing in  a  growing  tumor.  From  the  histological  investigation 
the  primary  change  appears  to  arise  in  the  tumor-cells  them- 
selves. While  this  cannot  be  determined  by  direct  microscopical 
observation,  it  is  shown  to  be  the  case  by  the  fact  that,  while 
one  tumor  goes  on  growing,  another,  in  the  same  host,  is  being 
absorbed.  That  the  primary  change  is  in  the  tumor-cells  has 
been  determined  by  studying  the  site  of  inoculation  in  normal 
and  in  immune  animals,  and  by  investigating  the  resistance 
which  tumors  induce  against  themselves,  as  described  below 
under  auto-immunization.  The  histological  appearances  are 
exactly  analogous  in  the  rare  phenomenon  of  the  healing  of 
spontaneous  tumors,  and  in  their  case  also  changes  in  the  tumor- 
cells  themselves  play  the  determining  role.  As  in  transplanted 
tumors,  one  spontaneous  tumor  may  be  absorbed  while  another 
continues  to  grow.  Whether  or  not  constitutional  hindrances 
to  gi-o^vth  also  develop,  as  in  transplanted  tumors,  has  not  yet 
been  determined. 

Examination  of  the  Site  of  Grafting. — When  a  minute  graft  is 
made  into  a  new  host  the  carcinoma-cells  persist  and  grow 
progressively.  The  supporting  scaffolding  of  blood  vessels  and 
connective  tissue  degenerates  and  is  supplied  afresh  by  the  new 
host  reacting  to  the  chemotactic  powers  of  the  cancer-cells  in 
such  a  specific  manner  that  the  structure  of  the  mother-tissue 
is  exactly  reproduced,  perhaps  after  years  of  continued  propaga- 

1  See  General  Bibliography. 


0 


i:i 


I 

to     ««      '  /r'r  h  ■•! 


i»i<ktm').s^ 


Plate  XXXVII. — High  power  view  of  the  formation  of  new  blood-vessel  and  stroma  scaf- 
folding for  a  graft  of  carcinoma  in  a  normal  rat.  (From  Woglom,  Fifth  Scientific  Re- 
port, Imperial  Cancer  Research  Fund,  1912.) 


CANCER    RESEARCH  173 

tion.  In  animals  immunized  by  normal  or  tumor  tissue  this 
specific  reaction  does  not  take  place.  Superficial  examination 
may  lead  to  the  conclusion  that  the  reaction  is  the  same,  but  the 
careful  examination  of  serial  sections  shows  that  neither  the 
connective  tissue  nor  the  blood-vessels  of  the  immune  host  pene- 
trate the  graft  in  the  same  way  as  in  normal  animals.  There  is 
a  reaction  in  immune  animals,  but  it  is  of  a  different  nature. 
In  the  immune  animal  the  cancer-cells  are  lying  in  a  single 
layer  against  a  solid  wall  of  thei  host's  tissues  at  a  time  when 
in  a  normal  one  the  graft  would  be  developing  into  a  well-rec- 
ognized miniature  tumor.  They  are  as  near  the  food  supply  as 
they  can  get,  and  are  not  immediately  or  directly  killed  by  some 
potent  cell-poison.  Their  architectural  powers  of  molding  a 
new  stroma  of  blood-vessels  and  connective  tissues  from  the 
host  appear  to  be  paralyzed,  and  ultimately  they  are  so  injured 
as  to  die  or  to  succumb  to  the  formation  of  scar-tissue.  The 
process  is  essentially  the  same  as  in  spontaneous  healing.  It  is 
more  acute  because  the  immunity  reaction  was  existent  before 
the  graft  was  introduced,  whereas  in  spontaneous  healing  it  is 
induced  concomitantly  with  the  grovsrth  of  the  tumor  which  it 
must  overtake. 

It  is  possible  to  proceed  further  by  applying  the  information 
thus  gained  to  an  analysis  of  the  difference  obtaining  when  in- 
oculation is  successful,  and  when  it  fails  in  animals  already 
bearing  tumors.  The  method  now  employed  is  to  inoculate  two 
tumor-strains,  either  simultaneously  or  at  intervals  one  after 
the  other,  and  then  to  examine  the  site  of  the  graft.  The  same 
histological  differences  described  above  are  again  found  between 
the  two  cases,  and  the  same  mechanism  of  active  resistance  may 
be  inferred. 

Reaction  Throughout  the  Body. — Apart  from  the  fact  that 
resistance  is  disseminated  throughout  the  body,  it  has  been 
found  that  the  connective  tissue  contains  an  excess  of  plasma- 
cells  during  the  time  when  the  resistance  is  developing. 

The  Relative  "Weights  of  the  Several  Organs. — The  growth  of 
a  tumor  hinders  the  growth  of  the  animal  bearing  it,  so  that 
very  young  animals  may  remain  dwarfs  as  compared  with 
others  of  the  same  age  that  have  remained  free  from  tumors. 
When  the  several  organs  of  tumor-bearing  animals  are  weighed 
and  expressed  as  ratios  of  the  total  body- weight  (minus  tumor), 
it  is  found  that  there  is  a  relative  hypertrophy^  as  compared 
with  the  normal.  Thus  hypertrophy  is  most  marked  for  the 
heart,  lungs,  liver  and  kidney,  and  spleen.  Owing  to  the  great 
fluctuations  occurring  in  the  weight  of  the  spleen  from  other 


174  THE    CANCER    PROBLEM 

causes,  the  interpretatiou  of  the  figures  for  this  organ  must  be 
made  with  caution. 

From  the  standpoint  of  immunity  it  is  of  importance  to  de- 
termine whether  this  hypertrophy  is  due  to  supplying  the  needs 
of  the  tumor,  or  whether  it  is  concerned  in  the  development  of 
resistance.  In  this  connection  the  heart,  lungs,  and  kidney  need 
not  be  considered.  The  spleen  is  particularly  interesting,  ow- 
ing to  the  apparent  rarity  of  metastases  in  it.  The  prominent 
part  played  by  the  liver  in  dealing  with  all  intoxications  also 
claims  attention  for  this  organ.  It  is  necessary  to  consider  the 
effects  produced  by  tumors  which  always  induce  resistance  and 
strains  which  never  do  so.  The  ratio  of  the  weight  of  the 
spleen  to  the  body-weight  varies  in  normal  animals  from  1 :54.4 
to  1:81.4,  the  body-weight  being  reckoned  after  removal  of  the 
alimentary  canal  plus  contents.  Similarly  the  liver  varies  from 
1:12  to  1:14.4.  The  hypertrophy  of  the  liver  and  spleen  is 
greater  in  animals  bearing  progressively  growing  tumors  than 
it  is  in  animals  in  which  tumors  are  undergoing  absorption  or 
have  already  been  absorbed.  It  follows,  therefore,  that  the 
hypertrophy  of  the  liver  and  spleen  occurs  independently  of 
the  influences  proceeding  from  a  tumor  and  calling  forth  active 
auto-immunization.  The  hypertrophy  is  concerned  in  promot- 
ing growth,  and  not  in  hindering  it.  The  tissue  of  the  hyper- 
trophied  organs  (liver)  has  undergone  no  modification  in  its 
immunizing  property. 

Auto-  or  Concomitant  Resistance.  — From  the  preceding  results 
it  has  been  possible  to  advance  yet  deeper  into  the  biological 
properties  of  the  cancer-cell,  and  to  determine  the  nature  of 
the  difference  between  tumors  growing  progressively  and  those 
exhibiting  only  transitory  growth. 

The  behavior,  on  transplantation,  of  propagated  tumor- 
strains  differs  greatly.  In  a  representative  series  of  eighty-six 
strains  of  different  primary  origin  there  are,  at  one  end,  strains 
which  take  in  100  per  cent,  of  all  animals,  which  grow  rapidly 
and  always  progressively,  and  which,  under  suitable  conditions, 
exhibit  metastases  in  a  high  proportion.  At  the  other  end  there 
are  strains  which,  although  they  take  in  100  per  cent.,  grow 
only  transitorily  and  all  become  absorbed.  Between  these  ex- 
tremes there  are  series  exhibiting  all  possible  combinations  of 
rates  of  growth,  proportions  of  takes,  and  of  absorptions. 

The  reason  for  the  difference  is  to  be  found  chiefly  in  the 
varying  degrees  to  which  the  tumor-cells  are  able  to  elicit  an 
active  reaction  against  themselves,  and  in  which  they  are  sus- 
ceptible to  it.  The  susceptibility  of  the  animal  plays  a  minor 
part.    Although,  theoretically,  natural  resistance  cannot  be  alto- 


CANCER    RESEARCH  175 

gether  dismissed,  practically  it  may  be  left  out  of  account,  and 
the  conception  of  variability  in  power  of  reaction  from  animal 
to  animal  substituted  for  it.  There  are  tumor-strains  which 
induce  a  powerful  auto-immunity  or  concomitant  immunity  in 
every  animal  which,  within  limits,  is  more  rapidly  effective  and 
of  higher  degree  the  larger  the  dose.  There  are  strains  which 
induce  no  such  reaction  whatsoever,  so  that  an  increase  of  dose 
merely  leads  to  larger  tumors  in  a  shorter  time.  Between  these 
two  groups  there  are  all  gradations. 

The  effect  of  the  primary  inoculation  on  a  secondary  inocula- 
tion is  the  same,  whether  the  latter  be  practiced  with  the  pri- 
mary tumors  present  or  after  their  surgical  removal.  According 
to  the  nature  of  the  tumor  first  inoculated  there  will  be,  re- 
spectively, no  resistance,  or  an  active  resistance,  to  the  sec- 
ondary inoculation.  In  the  latter  case  the  examination  of  the 
site  of  the  secondary  inoculation  shows  changes  identical  with 
those  found  upon  examination  of  early  grafts  from  animals 
which  have  been  actively  immunized  by  normal  or  tumor  tissue, 
namely,  absence  of  the  specific  blood,  vascular  and  connective 
tissue  scaffolding  on  the  part  of  the  host. 

Autologous  Inoculations.  — With  reference  to  their  reactions  to 
tumors  other  than  their  own  it  has  been  determined  that  mice 
with  primary  tumors  present  no  deviation  from  normal  mice, 
either  as  regards  suitability  for  inoculation  or  for  immuniza- 
tion. All  methods  of  immunization  are  powerless  against  the 
reinoculation  of  their  own  tumors.  While  resistance  is  effec- 
tively present  against  a  strange  tumor,  an  autologous  inoculation 
will  always  overcome  it  if,  indeed,  any  resistance  is  offered, 
of  which  there  is  no  evidence.  Conversely  an  inoculation  of  an 
animal's  own  tissues  is  equally  incapable  of  protecting  it  against 
the  growth  of  a  tumor  from  another  individual. 

Since  an  animal's  own  normal  tissues  do  not  induce  resistance 
to  an  homologous  cancer  inoculation,  there  is  no  reason  why  its 
own  cancer  tissue  should  do  so,  and  tumor-cells,  upon  autologous 
inoculation  into  immunized  animals  naturally  subject  to  cancer, 
probably  do  not  even  require  to  overcome  the  homologous  re- 
sistance. The  tumor-cells  are  indifferent  to  the  existence  of 
resistance  when  replaced  in  their  natural  host. 

Loss  of  Power  to  Induce  Resistance  and  Acquisition  of  Powers 
of  Continuous  Growth. — Tumor-strains  which,  although  taking 
in  a  high  percentage  of  cases,  exhibit  only  transitory  growth 
and  produce  active  resistance,  present  exactly  the  same  features 
as  do  normal  tissues  on  transplantation.  There  is  the  differ- 
ence, of  course,  that,  although  normal  tissue  cannot  be  grown  in 
an  indefinite  succession  of  hosts,  such  tumors  can  be,  if  trans- 


176  THE    CANCER    PROBLEM 

plantation  is  performed  sufficiently  early.  Of  s:reat  importance 
is  the  observation  that  from  mother-strains  exhibiting  these  phe- 
nomena there  may  be  obtained  daughter-strains  with  better 
powers  of  growth — which  are  even  possessed  of  progressive 
growth — in  every  animal,  and  which  are  able  to  produce  metas- 
tases in  a  high  percentage  of  animals.  Such  altered  daughter- 
strains  have  not  become  insusceptible  to  the  immune  reaction 
or  "seruni-fest."  As  grafts  they  remain  susceptible  to  resis- 
tance induced  by  normal  tissue  or  tumor,  but  they  have  lost  the 
power  to  induce  resistance  to  their  own  growth  and  to  the 
growth  of  other  tumors. 

This  change  must  be  of  great,  indeed  of  fundamental  im- 
portance, since  an  animal  200  to  400  times  the  weight  of  the 
dose  of  cells  can  be  rendered  absolutely  resistant,  and  an  evident 
resistance  is  produced  even  if  the  dose  be  only  1/3000  of  the 
weight  of  the  animal ;  but  after  the  change  the  power  to  induce 
resistance  is  lost  entirely,  for  evidence  of  its  retention,  even  in 
reduced  degree,  has  not  been  obtained  by  increasing  the  dose. 
The  changed  cells  no  longer  induce  hindrance  either  to  their 
own  growth  or  to  the  growth  of  other  tumors.  In  this  respect, 
therefore,  they  behave  in  normal  animals  in  the  same  way  as 
autologous  inoculations  of  spontaneous  tumor.  It  would  appear 
that  a  new  fact  bearing  on  the  correlation  of  growth  has  been 
brought  to  light  by  showing  how  progressive  powers  of  growth 
have  been  acquired  in  the  case  of  such  daughter-tumors. 

Hypersensitiveness.' — The  use  of  the  term  "hypersensitive- 
ness,"  as  of  "immunity,"  may  be  justified  only  by  convenience. 
The  condition  has  nothing  in  common  with  anaphylaxis,  and 
merely  implies  an  alteration  in  the  soil,  in  consequence  of 
which  tumors  grow  better. 

The  phenomenon  has  been  described  after  the  inoculation  of 
tumor  tissue  or  normal  tissue,  either  undamaged  or  treated  in 
various  ways,  as  by  heat  or  crushing.  It  is  not  an  antecedent 
stage  in  the  production  of  resistance,  but  rather  a  later  phe- 
nomenon. The  subject  is  not  thoroughly  cleared  up.  Appa- 
rently it  is  of  the  nature  of  a  neutralization  of  the  power  to 
react  with  active  resistance,  and  not  a  persistent  stimulus  to 
growth.  It  has  not  yet  been  found  possible  to  obtain  clear  evi- 
dence of  the  abolition  of  immunity  by  inoculating  crushed  ma- 
terial into  an  actively  resistant  animal. 

Possibility  of  Applying  Results  to  Explain  Nature  of  Cancer, — 
Active  resistance  is  effective  against  grafts  and  emboli,  and 
hardly  effective,  or  not  effective  at  all,  against  well-established 
tumors,  except  such  as  are  liable  to  spontaneous  healing  in 
consequence  of  auto-immunization.     A  slight  effect  of  active 


CANCER    RESEARCH  177 

resistance,  never  amounting  to  cure  or  persistent  holding  up  of 
growth,  can  be  obtained  on  strains  which  do  not  induce  auto- 
immunity, and  which  grow  progressively  in  consequence. 

A  problem  of  great  interest  centers  in  the  difference  between 
the  great  susceptibility  of  grafts  to  active  resistance  and  the 
relative  or  absolute  insusceptibility  of  established  tumors.  This 
contradiction  is  of  primary  importance  in  any  discussion  of  the 
nature  of  cancer  immunity.  It  has  not  yet  been  completely 
resolved,  but  the  conclusion  has  been  drawn  that  something 
circulating  in  the  fluids  and  acting  on  the  cancer-cells  is  re- 
sponsible for  the  histological  pictures  observed  (1)  for  grafts 
and  emboli  in  immunized  animals,  (2)  for  secondary  grafts  in 
animals  in  which  the  primary  inoculation  has  led  to  tumors 
which  ultimately  are  absorbed,  and  (3)  for  those  seen  during 
spontaneous  healing.  The  part  played  by  changes  in  the  cancer- 
cell  itself  is  brought  out  by  the  fact  that,  while  one  tumor  is 
absorbed,  another  continues  to  grow  in  the  same  host. 

SUMMARY 

In  a  recent  review  of  Ehrlich's  standpoint,  which  is  also  his 
own,  Apolant  ^  covers  very  much  the  same  ground  that  Bashford 
has,  but  there  are  a  few  divergencies,  not  so  much  as  to  facts, 
but  rather  as  regards  their  interpretation.  The  most  important 
differences  as  to  facts  are  that  Apolant  has  never  observed  any 
seemingly  recurring  fluctuations  in  the  rate  of  growth  and  in 
the  transplantability  of  tumors.  While  he  agrees  in  believing 
it  to  be  a  general  law  that  it  is  impossible  to  transplant  tumors 
into  a  strange  species,  he  claims,  in  opposition  to  Bashford, 
that  it  is  possible  to  produce  immunity  by  inoculating  the  nor- 
mal tumors  of  strange  species.  The  most  important  difference 
between  the  conclusions  of  these  two  schools,  however,  is  as  to 
the  nature  of  immunity.  While  Bashford  and  his  followers 
recognize  only  one  form  of  active  resistance,  Ehrlich  and  his 
school  hold  that  there  is  an  additional  form  of  immunity,  viz., 
atreptic  immunity. 

In  atreptic  immunity  the  presence  of  a  rapidly  growing 
tumor  so  withdraws  special  food-stuffs  that  a  second  tumor  is 
unable  to  establish  itself  if  inoculated,  and  secondary  growths 
cannot  develop.  Atreptic  immunity  is  also  found  when  a  tumor 
grows  only  transitorily  in  a  strange  species,  growth  ceasing 
when  the  food-stuff  transplanted  with  the  cells  has  become  ex- 
hausted.    This  interpretation  of  some  of  the  experimental  facts 

1  Apolant. — ' '  Die  experimentelle  Erf  orschung  der  Gesehwiilst., ' '  in  Kolle 
u.  Wassermann  's  Handbuch  der  pathogenen  Mikroorganismen,  Vol.  Ill,  1913. 


178  THE    CANCER    PROBLEM 

has  becu  applied  by  Ehrlich  to  explain  the  etiology  of  tumors. 
Their  origiu  is  attributed  to  a  decline  in  the  appetite  for  food 
by  the  cells  of  the  body  as  a  whole,  while  isolated  groups  of 
cells  retain  a  hunger  more  nearly  the  normal^  or  even,  but  only 
rarely,  exceeding  it.  For  a  full  discussion  of  these  theoretical 
matters  Apolant's  valuable  review  should  be  consulted.  Ehr- 
lich's  experimental  results  and  deductions  bring  him  into  a  cer- 
tain amount  of  contlict  with  the  facts  of  human  pathology, 
which  he  explains  away  by  stating  that  differences  are  due  to 
human  tumors  not  having  such  enormous  proliferative  energy 
as  mouse  tumors.  It  seems,  however,  that  safer  ground  is  oc- 
cupied by  those  whose  experimental  tumors  exactly  reproduce 
the  features  of  the  disease  as  known  in  man,  especially  the 
power  of  dissemination. 

Experiment  has  placed  some  old  views  on  the  nature  and 
growth  of  cancer  upon  a  new  and  firmer  basis,  by  proving  that, 
given  suitable  conditions,  a  small  group  of  cells,  when  intro- 
duced into  a  healthy  animal,  will  reproduce  all  the  character- 
istics of  cancer,  namely,  a  primary  growth,  infiltration  of  the 
surrounding  tissues,  and  secondary  growths  in  internal  organs 
and  in  the  lymphatic  glands.  This  experimental  reproduction 
of  the  disease  has  been  combined  with  the  demonstration  that 
the  surgical  removal  of  the  inoculated  cells  prevents  all  evil 
consequences  if  the  operation  be  performed  sufficiently  early; 
otherwise,  recurrence  takes  place,  or,  dissemination  having  al- 
ready occurred,  death  is  inevitable.  The  surgical  treatment  of 
cancer  is  thus  amply  justified. 

All  the  consequences  of  inoculating  cancer  cells  can  be  pre- 
vented by  a  previous  immunization,  but,  nevertheless,  such  im- 
mune animals  can  develop  tumors  of  their  own.  Thus  new  and 
important  evidence  has  been  obtained  that  cancer  arises  not  by 
the  introduction  of  something  from  without  (exogenous  origin) 
but  from  causes  peculiar  to  and  within  (endogenous)  each  indi- 
vidual organism. 

The  surmise  that  the  growth  of  cancer  is  limitless,  and  inde- 
pendent of  the  rest  of  the  body,  has  been  shown  by  propagation 
to  be  a  fact,  embodying  the  real  problem  of  cancer.  The  prop- 
agation of  cancer  has  afforded  opportunities  for  studying  the 
biology  of  the  tumor-cell,  as  regards  its  histology  and  the  fea- 
tures of  growth.  It  has  been  shov^m  that  histological  structures 
may  be  lost;  it  has  also  been  shown  that  the  pictures  often  in- 
terpreted to  mean  that  this  was  in  progress  in  man,  may  signify 
the  opposite,  namely,  a  differentiation  from  young  tumor  cells. 
The  tenacity  with  which  typical  structures  may  be  retained 
and  combined  with  powers  of  unlimited  growth,  has  given  ex- 


CANCER    RESEARCH  179 

perimental  data  which  has  been  accepted  by  some  as  proving 
that  the  essential  problem  is  the  same  for  benign  and  malignant 
tumors,  and  that  there  is  no  sharp  distinction  between  them,  for 
example,  according  to  the  view  of  certain  investigators,  that 
there  is  a  parasitic  cause  for  malignant  growths  but  not  for 
those  of  non-malignant  character. 

Some  facts,  according  to  Bashford,  stand  out  as  having  pos- 
sible bearings  upon  the  nature  of  cancer.  Tumors  vary  in  all 
degrees  in  their  power  to  induce  resistance  to  growth,  and  in 
their  susceptibility  to  it,  however  induced.  From  mother  mate- 
rial able  to  induce  resistance  there  has  been  derived  material 
which  has  lost  this  power,  and  which,  while  retaining  suscepti- 
bility to  resistance  as  a  graft,  has  acquired  powers  of  progres- 
sive growth  for  established  tumors. 

"A  mere  loss  of  power  to  induce  hindrance  to  their  own 
growth,  on  the  part  of  a  small  group  of  cells  in  the  circum- 
scribed area  within  which  a  cancer  arises,  would  not  explain  the 
origin  of  the  disease.  The  influence  of  all  the  rest  of  the  nor- 
mal tissue,  of  the  same  and  of  different  sorts,  must  remain  dom- 
inant, otherwise  the  abnormal  growth  would  be  diffuse  in  the 
tissues  in  which  cancer  arises.  The  loss  of  power  to  induce 
hindrance  to  their  own  growth,  combined  with  an  insuscepti- 
bility to  the  hindrance  elsewhere  in  the  body,  is  an  hypothesis 
having  more  to  commend  it.  It  is  conceivable  that  a  circum- 
scribed group  of  cells  may  become  insusceptible  to  the  constitu- 
tional forces  correlating  growth,  because  of  some  modification 
analogous  to  that  by  which  tumour-cells  lose  their  power  of  in- 
ducing resistance,  and  that,  although  susceptible  to  it  in  strange 
hosts,  they  are  indifferent  to  it  in  their  hosts  of  origin. 

''The  delicate  reactions  thus  far  revealed  are  all  of  a  new 
order,  and  are  probably  closely  interrelated.  They  were  not 
dreamed  of  a  few  years  ago.  At  present  their  study  appears  to 
show  that  the  etiology  of  cancer  is  complex,  and  compounded  of 
both  local  and  constitutional  conditions." 


SECTION    VII 

CLINICAL  COURSE;  DIAGNOSIS;  POSSIBLE  ER. 
RORS  IN  DIAGNOSIS 

CHAPTER   I 
CLINICAL    COURSE 

There  is  a  certain  amount  of  confusion  in  the  way  the 
terms  benign  (innocent)  and  malignant  are  applied  to  tumors. 
This  is  due  to  two  circumstances.  First,  to  the  fact  that  these 
terms  are  used  to  describe  the  clinical  course  as  well  as  the 
microscopical  structure.  Second,  that,  as  there  are  all  stages 
in  structure,  so  also  there  are  all  degrees  of  malignancy.  In 
neither  case  may  a  sharp  line  be  drawn,  although  it  has  often 
been  attempted. 

In  the  section  on  Histopathology  it  has  been  made  clear  that 
for  malignant  new  growths  there  are  all  gradations  in  structure, 
from  complete  retention  of  the  normal  character  of  a  gland — 
the  thyroid,  for  example — up  to  such  entire  loss  of  structure 
that  it  is  impossible  to  refer  the  growth  to  its  mother  tissue.  It 
is  customary  to  infer  the  degree  of  malignancy  from  the  extent 
to  which  the  normal  structure  is  retained.  In  a  general  way 
this  can  be  done.  An  epithelioma,  for  example,  showing  very 
marked  pearl  formation — owing  to  great  tendency  to  keratiniza- 
tion — would  usually  be  held  to  be  less  malignant  than  one  in 
which  there  was  little  such  tendency.  No  hard  and  fast  rela- 
tion can  be  established,  however,  between  structure  and  ma- 
lignancy. 

The  bankruptcy  of  a  purely  histological  classification  is 
shown  by  the  fact  that  occasionally  pathologists  in  Germany 
have  gone  so  far  as  to  describe  a  "benign  tumor  with  metastasis 
formation,"  meaning  that,  notwithstanding  the  retention  of 
normal  (benign)  structure,  the  pathological  findings  and  clini- 
cal course  showed  that  clinically  the  tumor  was  really  malig- 
nant. 

180 


CLINICAL    COURSE  181 

Thus  it  comes  about  that  the  combination  of  the  clinical 
course  with  the  histological  and  pathological  examination  is 
the  only  reliable  basis  upon  which  the  nature  of  a  tumor  can 
be  determined  with  approximate  certainty.  Structure  of  itself 
is  not  a  criterion  of  what  the  biological  behavior  of  a  tumor 
will  be,  although  it  is  a  useful  guide.  Clinical  examination 
alone  is  often  insufficient  to  determine  either  the  nature  of,  or 
the  treatment  appropriate  to,  a  tumor.  Just  as  a  careful  clin- 
ician will  call  in  the  pathologist  because  he  cannot  make  up  his 
mind,  so  also  the  pathologist  will  sometimes  not  be  able  to  come 
to  a  conclusion,  and  both  together  may  be  baffled  or  even  proved 
wrong  by  the  after  course  of  events.  In  the  present  state  of 
our  knowledge,  therefore,  the  essential  similarity  of  tumors 
must  be  insisted  on  in  connection  with  the  progress  and  diag- 
nosis of  cancer. 

The  onset  of  cancer,  as  of  any  tumor,  is  insidious,  and,  in  its 
earliest  stages,  without  evident  manifestations.  The  progress 
of  the  disease  differs,  not  only  as  between  one  kind  of  benign 
or  malignant  new  growth  and  another,  and  between  one  part  of 
the  body  and  another,  but  also  as  between  the  same  kinds  of 
growths  occurring  in  the  same  sites,  but  in  different  individuals. 
Hence  a  general  description  must  be  a  loose  description.  To 
avoid  misunderstanding  it  may  be  explained  that  a  malignant 
new  growth,  if  allowed  to  progress,  always  causes  death,  whereas 
a  person  with  a  benign  new  growth  dies  with  it,  but  not  of  it. 
Since  benign  and  malignant  new  growths  have  but  few  prop- 
erties in  common,  it  can  only  be  positively  asserted  of  them 
in  general  that  the  vast  majority,  if  not  all,  (1)  arise  in  a  single 
circumscribed  area;  (2)  grow  progressively  up  to  death;  and 
(3)  if  removed  early  enough  are  curable. 

The  earliest  stage  of  cancer  is  an  unrecognizable  prolifera- 
tion of  cells  which  proceeds  until  it  attracts  attention  in  conse- 
quence of  the  appearance  of  a  lump  or  an  ulcer.  An  ulcer  may 
supersede  a  lump,  or,  on  the  other  hand,  it  may  attract  atten- 
tion without  any  preceding  lump  having  been  detected.  Plate 
IV  shows  the  natural  size  and  the  microscopical  structures  of 
an  early  epithelioma  of  the  tongue,  and  illustrates  how  small 
such  an  ulcer  may  be  when  its  dangerous  nature  is  already  evi- 
dent by  signs  of  spreading  into  the  adjacent  tissues.  An  illus- 
tration is  also  given  (Plate  VII)  of  a  nodule  (natural  size) 
in  the  breast,  for  which  the  entire  organ  was  removed.  Under 
higher  magnification  it  is  evident  that  at  this  early  stage  a 
small  but  rapidly  growing  soft  carcinoma  was  present. 

In  these  early  stages,  except  for  the  presence  of  a  lump  in 
the  breast  or  a  small  ulcer  on  the  tongue,  there  are  no  symptoms. 


182  THE    CANCER    PROBLEM 

Pain  is  entirely  absent  in  the  breast,  and  the  slight  inconveni- 
ence of  an  ulcer  on  the  tongue  would  not  suffice  to  send  any — 
in  fact  none,  except  the  most  nervous  and  anxious — to  the 
surgeon. 

In  this  connection  it  should  be  emphasized  that  cancer  is  not 
necessarily  painful  at  any  stage  of  its  progress,  and  particularly 
that  pain  is  usually  absent  in  early  stages.  The  public  are  so 
obsessed  with  the  painful  and  shocking  nature  of  the  disease 
that  a  "harmless,''  painless  lump  is  too  often  neglected.  Pain, 
however,  may  be  present  very  early.  When  a  nerve  is  involved 
it  may  be  the  first  sign  to  attract  attention;  so  also  if  bone  is 
attacked,  or  if  there  is  ulceration  either  on  the  surface  of  the 
body  or  in  the  alimentary  canal.  The  later  stages  are  usually 
associated  with  pain  of  all  degrees  of  intensity.  This  applies 
more  emphatically  to  all  stages  of  the  primary  growth.  After 
a  primary  or  ulcerating  tumor  has  been  removed,  metastases 
in  internal  organs  may  cause  no  pain  and  but  little  discom- 
fort. 

Whether  carcinomatous  or  sarcomatous,  the  rate  at  which  a 
malignant  new  growth  increases  in  size  varies  greatly.  Some 
grow  very  slowly,  others  very  rapidly.  A  nodule  in  the  breast 
may  remain  of  about  the  same  size  for  only  a  few  months,  or 
it  may  be  several  years ;  and  an  ulcer  may  even  appear  to  heal. 
Some  forms  of  round-celled  sarcoma,  and  especially  melanotic 
sarcoma,  grow  with  alarming  rapidity.  But  the  rate  of  growth 
is  not  always  a  criterion  as  to  the  danger,  nor  of  the  rapidity 
of  dissemination. 

The  size  of  the  primary  neoplasm  may  not  indicate  the  real 
danger.  For  example,  a  minute  melanotic  sarcoma  may  already 
have  widespread  secondary  nodules  all  over  the  body  and  huge 
masses  in  the  liver.  A  lesion  that  looks  like  a  small  ulcer  on 
the  tongue  may  really  be  spreading  out,  fan-like,  into  the 
muscles  and  along  under  the  mucous  membrane,  and  there  may 
be  such  involvement  of  the  lymphatic  glands  that  an  operation 
for  what  looks  like  early  cancer  of  the  tongue,  will  be  performed 
only  as  a  palliative  measure,  or  as  an  operation  insuring  a 
comfortable  prolongation  of  life. 

A  slow-growing  and  apparently  innocent  tumor  may,  after 
years,  suddenly  develop  into  a  rapidly  fatal  form  of  cancer. 
As  a  rule,  the  rate  of  grow^th  is  quickest  in  the  young.  In  the 
old  it  may  be  so  slow,  as  in  the  atrophic  scirrhus  of  the  breast 
in  old  women,  that  such  tumors  are  often  best  left  alone. 
Progress  is  usually  most  distressingly  rapid  in  healthy,  robust 
individuals. 

In  many  forms  of  cancer  there  are  periods  of  improvement. 


CLINICAL    COURSE  183 

A  rodent  ulcer  may  be  healing  at  one  edge  and  extending  at 
another.  Similarly,  in  cancer  of  the  breast,  a  period  of  quies- 
cence or  of  actual  amelioration  may  set  in  either  in  the  primary 
neoplasm  or  in  the  secondary  deposits.  This  may  be  hardly 
apparent,  and  may  be  the  result  of  sloughing  or  of  the  ulcerat- 
ing out  of  an  invaded  gland.  Real  periods  of  stay  of  progress, 
or  actual  diminution  in  size,  to  be  followed  by  recrudescence, 
are  by  no  means  infrequent.  While  these  periods  of  quiescence 
stimulate  to  a  search  for  methods  of  controlling  growths,  they 
also  awaken  false  hopes,  and  obtain  credit  for  allegations  of  the 
efficacy  of  remedies  of  which  these  interesting  phenomena  are 
entirely  independent. 

The  clinical  course  or  progress  of  cancer  is  the  exact  counter- 
part of  the  histological  or  microscopical  findings.  From  the 
limited  area  in  which  the  continuous  growth  has  started,  the 
cells  spread  throughout  the  body,  producing  baneful  effects 
everywhere,  until  death  ensues.  It  is  thus  as  essential,  in  study- 
ing the  clinical  course  of  the  disease,  to  separate  the  primary 
effects  from  the  secondary  consequences  of  the  growth,  as  it  is 
necessary  to  separate  the  pathological  and  microscopical  find- 
ings into  primary  and  secondary  growths.  It  is  only  by  so 
doing  that  a  true  conception  may  be  obtained  of  the  local  and 
the  constitutional  effects  of  the  disease,  as  distinguished  from 
the  parts  played  in  causation  by  changes  limited  to  the  cells 
confined  within  the  circumscribed  area,  and  by  constitutional 
conditions  which  may  obtain  in  the  body  as  a  whole. 

At  the  risk  of  repetition  it  may  be  recalled  that  histological 
and  experimental  study,  as  well  as  surgery,  agree  in  disproving 
the  ancient  view  that  cancer  is  primarily  a  "constitutional" 
disease,  in  the  sense  in  which  the  term  was  used  by  Sir  James 
Paget,  in  a  debate  before  the  Pathological  Society  of  London  in 
18T4  (see  p.  108).  Even  more  emphatically  these  methods  of 
investigation  dismiss  as  absurd  the  idea  that  cancer  is  an  "out- 
crop" from  deep-seated  "roots"  pervading  the  system  as  a  whole, 
but  only  sending  up  offshoots  to  the  surface  at  one  spot.  It  is 
necessary  to  emphasize  these  points  because  of  the  recent  wide 
dissemination,  in  the  lay  press  and  by  quasi-medical  books,  of 
these  antiquated  notions,  and  because  of  the  revival  in  the 
minds  of  the  public  of  the  old  despairing  doctrine  that  cancer 
cannot  be  cut  out  once  and  for  all,  but  that  if  cut  out  in  one 
place  crops  out  in  another.  The  facts  of  pathology,  the  normal 
clinical  course  of  the  disease,  and  the  facts  of  surgical  experi- 
ence are  one  and  all  distorted  or  actually  falsified  by  presenting 
them  in  this  way. 

The  process  of  spread  is  exactly  the  opposite.     From  the 


184  THE    CANCER    PROBLEM 

primary  focus  itself  the  offshoots  reach  outward  throughout  the 
body  as  a  whole,  just  as  they  spread  to  a  neighboring  tissue  and 
produce  their  primary  and  secondary  eifects.  In  their  immedi- 
ate enyironment,  according  to  their  situation,  they  destroy  the 
skin  or  mucous  membranes,  producing  extensive  ulceration; 
they  also  destroy  the  eyes,  the  ears,  eyen  cartilage  and  bone. 
By  invading  the  walls  of  blood  vessels,  especially  veins,  they 
cause  repeated  and  exhausting  hemorrhage.  They  may  press 
upon  the  esophagus  or  trachea,  and  may  cause  starvation  or 
respiratory  difficulties.  Large  and  important  organs  like  the 
lungs,  kidneys,  liver,  pancreas,  thyroid,  stomach,  and  intestines, 
may  have  their  functions  seriously  interfered  with.  These  ef- 
fects are  all  caused  by  the  cancer-cells  growing  into  or  pressing 
upon  their  immediate  surroundings. 

The  secondary  consequences  arise  from  the  secondary  growths 
which  develop  in  the  neighboring  l}TQphatic  glands  and  in  dis- 
tant parts  of  the  body  from  the  offshoots  of  the  primary  focus, 
so  that  what  was  originally  occurring  around  it  alone,  comes  to 
pass  in  multiple  centers  and  in  many  parts  of  the  body.  Wher- 
ever a  secondary  growth  is  situated  it  may  produce  exactly  the 
same  effects  as  a  primary  growth.  The  earlier  and  the  more 
numerous  the  secondary  manifestations,  the  more  quickly  does 
the  patient  succumb.  The  progress  of  the  disease  to  a  fatal 
issue  may  be  painless,  as  when  a  secondary  growth  in  the  brain 
produces  unconsciousness.  Death  may  be  sudden ;  but  too  often 
it  is  lingering  and  painful,  complicated  by  the  secondary  as 
well  as  the  primary  effects  leading  to  extensive  ulceration  or 
abscess  formation,  with  resulting  septic  poisoning. 

There  is  a  widespread  misconception  of  the  cachexia  or  wast- 
ing sometimes  associated  with  the  progress  both  of  benign  and 
malignant  tumors.  The  condition  is  not  specific  for  malignant 
disease,  and  the  seeking  of  advice  or  the  making  of  a  diagnosis 
should  never  be  delayed  for  its  appearance.  In  the  vast  major- 
ity of  cases  it  is  a  late  manifestation  consequent  upon  the  ad- 
vance of  the  disease,  and  it  is  no  longer  regarded  as  an  ante- 
cedent constitutional  condition  upon  which  cancer  develops. 
Where  there  is  ulceration  with  septic  absorption,  or  interfer- 
ence with  the  food  supply — for  example,  chronic  indigestion  or 
stricture — then  the  so-called  cachectic  state  is  more  frequent 
and  usually  more  marked.  Widespread  dissemination  is  also 
often  accompanied  by  marked  cachexia,  as  is  the  occurrence  of 
repeated  hemorrhage. 

The  duration  of  life  of  cancer  subjects  varies  within  wide 
limits,  from  a  few  months  to  many  years,  and  may  be  endured 


CLINICAL    COURSE  185 

with  little  more  than  discomfort.  It  is  usually  assumed  that 
the  average  duration  of  life  is  from  two  to  three  years. 

Cathcart  ^  has  well  summarized  the  clinical  distinction  be- 
tween innocent  (benign)  and  malignant  new  growths,  and  the 
mode  of  progress  and  of  death,  as  follows: 

"Since  the  terms  'innocent'  and  'malignant'  are  so  intimately 
bound  up  with  this  discussion,  it  is  necessary  that  we  should 
try  at  the  outset  to  grasp  their  meaning  when  applied  to 
tumours.  The  contrast  between  a  characteristic  example  of 
each  class  of  tumour  is  well  expressed  by  Mr.  Bland-Sutton — 
now  Sir  John  Bland-Sutton — when  he  says  'The  baneful  effects 
of  innocent  tumours  depend  entirely  upon  their  environment, 
but  malignant  tumours  destroy  life  whatever  their  situation.' 

"If,  now,  we  try  to  see  how  it  is  that  malignant  tumours  de- 
stroy life  whatever  their  situation,  we  shall  find  that  they  pro- 
duce their  evil  effects  differently  in  different  cases.     It  may  be : 

"(a)  By  excessive  local  growth,  whereby  the  tumour  absorbs 
for  its  own  use  nutriment  which  would  otherwise  have  supplied 
the  normal  tissue ; 

"(b)  By  degeneration  and  hemorrhage,  whereby  the  blood  is 
deteriorated  and  wasted; 

"(c)  By  local  dissemination,  in  which  case  the  tumour  sends 
offshoots  into  the  surrounding  tissue  at  a  little  distance  from 
itself.  These  offshoots  form  new  centers  of  growth,  and  thus 
act  like  an  excessive  overgrowth  of  the  original  focus  in  ex- 
hausting the  patient; 

"(d)  By  infiltration  of  the  surrounding  tissues,  the  tumour 
invading  and  destroying  all  the  structures  which  it  touches; 

"(e)  By  lymph  dissemination,  whereby  the  blood  is  the  agent 
by  which  the  foci  are  distributed  to  different  parts  of  the  body. 

"These  various  ways  of  causing  death  may  not  be  all  present 
in  the  same  case.  Those  which  have  been  placed  first  are  asso- 
ciated with  the  less  malignant  forms  of  tumour,  and  those  at  the 
end  of  the  list  with  the  more  malignant  forms.  The  less  malig- 
nant manifestations  are  more  frequently  present  alone,  while 
the  others  are  more  frequently  combined.  Thus  local  growth 
may  destroy  life  without  any  form  of  dissemination,  but  if  local 
infiltration  occurs,  dissemination  by  the  blood-  or  lymph-stream 
is  generally  present  also. 

"One  well-known  practical  test  of  malignancy  is  'return  after 
removal.'  This,  of  course,  means  return  after  the  removal  of 
all  visible  portions  of  the  tumour.  Such  return  is  an  outcome 
of  what  has  just  been  described  as  local  dissemination,  infiltra- 

1  Cathcart,  C.  W. — ' '  The  Essential  Similarity  of  Innocent  and  Malignant 
Tumours:   A  Study  of  Tumour  Growth,"  Bristol,  1897. 


186  THE    CANCER    PROBLEM 

tion,  or  dissemination  by  blood-  or  lymph-stream.  It  depends 
upon  the  power  of  the  cells  to  break  free  from  the  original  focus 
and  to  develop  a  fresh  mass  of  tnmour-iijrowth  when  carried  to 
a  new  part  of  the  patient's  body.  'Return  after  removal,'  there- 
fore is  not  an  additional  manifestation  of  malignancy ;  ^  only 
an  unfortunate  way  of  clinically  proving  that  certain  malignant 
features  have  undoubtedly  been  present  in  a  particular  case. 

"In  contrast  with  'nuilignant'  tumours,  those  which  are  'inno- 
cent' may  be  said  to  have  characters  negative  to  those  of  the 
malignant  forms.  A  typically  innocent  tumour  does  not  injure 
its  host's  life  by  excessive  growth,  it  does  not  infiltrate  the  tis- 
sues which  surround  it,  and  it  does  not  give  rise  to  new  tumours 
either  by  'local  dissemination'  or  at  a  distance,  when  carried 
by  the  blood-  or  lymph-stream.  While,  however,  it  is  possible 
to  say  all  this  of  some  tumours,  there  are  others  in  which  the 
line  of  demarcation  between  the  innocent  and  malignant  char- 
acters is  not  a  sharp  and  well-defined  one.  In  other  words,  the 
two  classes  of  tumour  are  not  distinct,  but  differ  only  in  de- 
gree." 

Death  may  come  on  suddenly  and  painlessly  from  hemor- 
rhage or  embolus,  long  before  it  would  occur  mercifully  from 
sheer  advancing  enfeeblement.  Often,  however,  it  only  follows 
upon  a  long  period  of  suffering  from  a  discharging,  ulcerated 
surface.  At  certain  sites,  when  communications  become  estab- 
lished between  one  viscus  and  another,  there  may  be  other  and 
even  more  distressing  complications.  Many  patients  die  with 
cancer  but  not  of  it,  owing  to  the  merciful  intervention  of  some 
other  illness.  Many  die  in  relatiA^e  comfort,  not  of  the  primary 
growth,  which  has  been  cured,  but  of  the  secondary  deposits  in 
internal  organs. 

In  concluding  this  sketch  of  the  natural  progress  of  cancer, 
reference  must  be  made — since  animal  experiment  has  given  to 
it  additional  interest,  and  has  eliminated  skepticism  as  to  its 
occurrence — to  the  spontaneous  cure  of  the  disease.  But  owing 
to  the  faulty  manner  in  which  the  pathological  details  of  the 
cases  of  spontaneous  cures  ^  are  described,  it  is  impossible  to 
estimate  how  frequent  this  occurrence  may  be.  For  cancer  of 
the  mamma  in  mice  it  has  been  determined  that  it  does  not 
occur  once  in  a  hundred  cases;  it  is  not  more  frequent  in  the 
human  subject. 

1  It  is  often  falsely  so  represented,  as  in  the  case  of  quacks  who  offer 
to  cure  cancer  provided  it  has  not  been  touched  by  the  knife.  Vide  pre- 
ceding page    (183)    with   reference   to   "roots"  of  cancer. 

*See  General  Bibliography. 


CLINICAL    COURSE  187 


SUMMARY 


Careful  study  of  the  clinical  course  of  cancer,  as  revealed  in 
the  hospital  and  the  experimental  laboratory,  emphasizes  the 
necessity  of  correlating  clinical  observation  with  histological 
and  pathological  examination,  in  order  to  determine  the  true 
nature  of  a  tumor. 

Accumulated  evidence  so  obtained  leads  to  the  inevitable 
conclusion  that  cancer  is  absolutely  local  in  its  beginning,  ex- 
tension taking  place  from  this  primary  focus. 

The  rationality  of  the  early  surgical  removal  of  this  localized 
manifestation,  and  the  possibility,  by  this  means,  of  effecting  a 
cure,  are  given  additional  proof  by  the  study  of  the  clinical 
course  of  the  disease. 


CHAPTER    II 
DIAGNOSIS 

CLINICAL 

Canceb  may  be  suspected,  by  patient  or  physician,  in  conse- 
quence of  pain,  a  tumor,  an  ulcer,  or  prolonged  indigestion ;  or 
the  first  cause  of  alarm  may  be  jaundice,  and,  in  the  case  of  the 
uterus,  hemorrhage.  The  complaint  may  be  even  more  vague — 
"loss  of  flesh,"  "unhealthy  appearance,"  or  it  may  be  quite 
indefinable  on  the  patient's  part. 

The  foregoing  clinical  description  will  have  made  clear  how 
difficult  it  is  at  times  to  determine  the  exact  nature  of  a  pa- 
tient's illness,  even  in  the  presence  of  an  obvious  tumor.  A 
distinction  may  be  drawn  between  external  and  internal 
growths,  since  in  the  case  of  the  former,  inspection  and  exam- 
ination can  be  more  complete.  The  difficulties  are  greater  in 
internal  conditions,  especially  if  attention  be  not  aroused  by  a 
visible  or  palpable  tumor.  The  relative  difficulty  is  well 
brought  out  in  the  table  on  the  errors  of  diagnosis  (Section  VH, 
Chapter  3,  p.  195).  It  will  also  be  equally  obvious  that  the 
history  of  the  timior,  if  one  be  present,  is  not  an  absolute  guide. 

On  the  surface  of  the  body,  or  where  the  site  is  easily  acces- 
sible, very  careful  inspection  and  palpation  or  the  handling  of 
the  suspicious  area  are  possible  without  accessory  methods  of 
diagnosis.  In  other  sites,  such  as  the  stomach,  intestines,  rec- 
tum, esophagus,  bladder,  etc.,  special  methods  are  essential,  and 
such  have  been  devised. 

The  clinical  examination  for  the  purposes  of  diagnosis 
takes  special  account  of: 

(a)  Site  (in  limbs,  bones,  or  muscles;  in  abdomen,  wall,  or 

what  organ;  secondary  or  primary). 

(b)  size  (real  or  apparent). 

(c)  shape  or  contour,  edge  (cyst,  lobulated  or  smooth). 

(d)  consistence,  pulsation,  translucency  (cysts). 

(e)  movable  or  fixed  (relation  to  surrounding  tissue,  skin 

for  ulceration,  bone,  hollow  or  solid  organs). 

(f)  vascularity,  pulsation, 

(g)  auscultation   (aneurysm,   "wind"). 

188 


DIAGNOSIS  189 

In  eliciting  the  necessary  data  upon  which  to  base  a  clinical 
diagnosis  of  cancer,  it  has  been  my  custom  to  use  the  following 
"Special  Cancer  History"  blank.  This  also  gives  a  convenient 
means  of  recording  other  data  bearing  upon  the  case,  such  as 
microscopic  examination,  previous  treatment,  subsequent  his- 
tory, etc. 

SPECIAL  CANCER  HISTORY 

Special    Number Date 

Name    

Address 

Case    Number Service    of 

Sex Age Married    or    Single 

Nationality       Occupation    

If  Female :   Children Miscarriages 

Were    Children    Nursed  ? 

Any    Breast   Complications   During   Nursing? 

Any  Lacerations  of  Cervix? Perineum? 

Condition   of    Teeth 

Prolonged   Irritation  or   Traumatism  Directly  at  Site  of   Primary  Lesion 

Prolonged  Irritation  in  Close  Proximity  to  but  Not  Directly  at  Site  of 
Primary  Lesion 

Place  of  Birth   (Country,  Town,  or  County) 

Residence  at  Time  of  Onset  of  Disease 

Habits  with  Reference  to: 

(a)  Alcohol 

(b)  Tobacco 

(c)  Drugs   (Morphin,  Cocain,  Etc.) 

Previous   General   Diseases 

Previous  Skin  Diseases 

Previous  Diseases  Affecting  Site  of  Cancer 

T,.  .      \  Clinical 

Diagnosis   ]  Microscopic .....[ 

Pathologist 

Location   of  Primary  Lesion 

Secondary    Lesions 

Did  Secondary  Manifestations  Follow  any  Form  of  Treatment  ? 

Were  There  any  Other  Cases  of  any  Form  of  Cancer  in  House  or  Neigh- 
borhood at  Time  Symptoms  Were  First  Observed,  or  Within  Recent 
Years? 

Note  Particularly  any  Circumstances  Suggestive  of  Contagion  or  In- 
fection  

Family  History  with  Reference  to  Cancer 

Previous  Treatment  by   Others 

Treatment : 

(a)  Operative    

(b)  Medicinal    (Enzymes,   Sera,  etc.)  . 

(c)  Caustics     , 

(d)  X-rays 

(e)  Radium 

(f )  Fulguration     

State  whether  (b),  (c),  (d),  (e),  (f)  were  used  Previous  to  or  Follow- 
ing   Operation 

Eventual    History 

Remarks    


190  THE    CANXER    PROBLEM 

There  is  danger  that  palpation  and  other  nianipnlative  liand- 
ling,  if  not  done  gently,  may  be  the  means  of  spreading  the 
disease  into  surrounding  tissues,  lymph  channels,  and  perhaps 
even  into  the  lumen  of  veins  whose  walls  are  already  infiltrated. 
(See  Section  XI,  Chapter  1,  p.  348.) 

These  considerations  may  leave  a  diagnosis  uncertain.  Ex- 
ploratory operation  is  then  resorted  to,  for  the  twofold  purpose 
of  ascertaining  the  true  nature  of  the  tumor,  and  of  determin- 
ing the  appropriate  treatment. 

MICROSCOPIC 

In  all  cases  the  clinical  diagnosis  should  be  accomplished  by 
a  microscopical  examination  of  the  growth  by  a  competent 
pathologist,  who  should  be  fully  in  the  confidence  of  the  sur- 
geon and  have  all  the  available  clinical  evidence  placed  at  his 
disposal.  Under  certain  circumstances  it  may  even  be  advisable 
to  have  the  pathologist  present  at  the  operation,  especially  if  it 
be  exploratory.  While  the  patient  is  under  light  anesthesia  a 
microscopic  examination  of  sections  may  thus  be  made.  Serial 
microscopic  sections  should  be  made  in  all  except  the  most 
patent  cases.  A  full  history  of  each  given  case  should  be  sub- 
mitted to  the  pathologist,  along  with  the  section  for  microscopic 
study.  The  practice  of  simply  submitting  a  preparation  for 
microscopical  study  is  to  be  deprecated,  and  it  is  gratifying  to 
note  that  it  is  now  largely  abandoned.  There  is  nothing  more 
remarkable  in  the  pronouncement  of  a  skilled  pathologist  that 
the  appearance  under  the  microscope  is  that  of  a  tumor,  malig- 
nant or  benign,  where  the  subsequent  course  of  events  proves 
the  opposite,  than  there  is  in  the  discovery,  by  the  pathologist 
in  the  autopsy  room,  of  the  errors  of  the  clinician,  be  he  physi- 
cian or  surgeon.  The  interests  of  the  pathologist  and  the  sur- 
geon are  one  and  the  same,  namely,  the  best  interests  of  the 
patient,  even  if  doubts  after  a  microscopical  examination 
render  it  the  wiser  policy  to  treat  as  if  a  malignant  new  growth 
were  present,  although  this  is  not  known  with  certainty  to  be 
the  case. 

In  perhaps  the  majority  of  instances  the  true  nature  of  the 
growth  can  be  discovered  after  the  microscopical  examination 
of  a  small  number  of  sections  of  tissue  removed  for  purposes  of 
diagnosis.  It  is  always  to  be  borne  in  mind,  however,  that  this 
may  not  be  the  case,  and  that  the  part  which  is  malignant  may 
not  be  found  until  many  sections  have  been  studied.  It  is  also 
to  be  remembered  that  there  is  a  possibility  of  a  negative  result 
being  due  to  the  presence  of  necrosis  of  tumor  tissue,  to  the 


DIAGNOSIS  191 

sloughing  away  of  the  base  of  an  ulcer,  or  to  cutting  out  a 
portion  which  does  not  reveal  the  true  nature  of  the  growth, 
for  the  simple  reason  that  we  have  no  absolutely  certain  criteria 
to  guide  us.  A  number  of  sections,  cut  in  series,  should  there- 
fore be  examined  in  all  doubtful  cases.  Small  ulcers  or  growths 
may  be  sectioned  from  end  to  end  and  examined. 

The  following  is  a  case  in  point : 

Epithelioma  of  Lip  and  Glands  of  Neck. — J.  L.,  male,  aged 
62.  Thirty-five  years  ago  the  patient  was  bitten  on  the  chin  by 
a  horse.  The  scar  resulting  from  this  wound  is  still  visible, 
near  the  middle  line,  about  on  a  level  with  the  alveolar  border. 
About  five  years  ago  the  patient  noticed  a  sore  on  the  right  side 
of  the  lower  lip.  This  was  indurated  and  tender.  He  was  ad- 
mitted to  the  hospital  December  28,  1906.  On  December  30th, 
the  mass,  about  the  size  of  the  end  of  the  thumb,  on  the  ver- 
milion border,  was  removed,  together  with  a  V-shaped  section 
of  the  lip.  The  glands  of  the  neck,  including  the  submaxillary, 
were  removed.     Recovery  uneventful ;  no  recurrence. 

A  pathologist  of  prominence  reported  the  specimen  to  be 
absolutely  non-malignant.  Clinical  evidence  of  malignancy 
being  so  apparent  I  requested  further  examination  of  the  speci- 
men. A  number  of  additional  sections  were  examined,  with  the 
final  report  of  undoubted  malignancy. 

This  case  illustrates  the  fact  that  one  should  not  lean  too 
heavily  upon  a  negative  pathological  report.  The  clinical  evi- 
dence of  malignancy  in  this  case  was  conclusive,  yet  it  was  only 
after  careful  and  prolonged  search  that  microscopic  evidence 
thereof  could  be  found. 

Many  similar  observations  from  my  own  experience  and  that 
of  others,  might  be  cited  to  emphasize  this  point. 

SERODIAONOSIS 

The  difficulties  to  which  attention  has  been  called  have  led  to 
the  active  search  for  some  means  of  diagnosing  cancer  by  exam- 
ining the  fluids  and  excreta  of  the  body,  especially  the  serum 
and  the  urine.  Every  now  and  then  a  new  diagnostic  test  of 
cancer  is  announced. 

Diagnostic  value  is  attached  by  some  observers  to  the  pres- 
ence of  some  abnormal  product  in  the  urine,  or  to  the  excess  or 
absence  of  a  normal  constituent. 

Salomon  and  Saxl,^  in  1911,  suggested  a  test  for  carcinoma, 

based  upon  the  supposed  presence,  in  the  urine  of  such  patients, 

'  Salomon  and  Saxl. — ' '  Eine  Sehwef elreaktion  im  Harne  Krebskranker, ' ' 
Wien.  Uin.  Woch.,  1911,  xxiv,  No.  13,  449;  Deutsch.  med.  Woch.,  1912, 
xxxviii,  53. 


192  THE    CANCER    PROBLEM 

of  a  sulphur-containing  substance,  which,  treated  with  barium 
chlorid,  yields  barium  sulphate.  He  reported  positive  results 
in  70  per  cent,  of  cases.  Others,  notably  Kaldeck,^  Pribram,- 
jMurachi,^  and  Petersen/  found  the  reaction  positive  in  some 
cases  of  carcinoma.  They  attached  little  importance  to  it,  how- 
ever, for  the  reasons  that  it  was  not  always  positive  in  well- 
recognized  cancer,  and  that  it  was  positive  in  the  presence  of 
other  diseases.  Greenwald,^  of  Moimt  Sinai  Hospital,  New 
York  City,  tested  the  procedure,  reaching  the  following  con- 
clusion : 

''No  differences  were  found  to  exist  between  the  urines  of 
patients  with  carcinoma  and  other  diseases,  and  normal  indi- 
viduals, in  the  amount  of  barium  sulphate,  either  absolute  or 
relative  to  the  total  sulphur,  precipitated  by  the  procedure  of 
Salomon  and  Saxl.  It  is  therefore  considered  that  the  test  is  of 
no  value  in  the  diagnosis  of  carcinoma." 

The  methylene  blue  test  in  the  urine  of  cancer  patients,  pro- 
posed in  1911,  by  Fuhs  and  Lintz,^  was  tested  by  Verbrycke  ' 
in  50  non-maligiiant  cases,  4  cases  of  gastric  carcinoma,  and 
1  probable  cancer,  with  positive  results  in  15  cases,  partially 
positive  in  13,  and  negative  in  27.  Of  the  4  cancer  cases,  it 
was  positive  in  1,  partially  positive  in  2,  and  negative  in  1. 
"From  the  number  of  positive  results  in  certain  non-malignant 
cases,"  he  said,  "it  is  evident  that  the  test  cannot  even  be  cred- 
ited with  giving  contributory  evidence  when  positive.  Again, 
if  the  test  is  of  any  value,  it  should  certainly,  in  cases  like  the 
above,  give  positive  results.  Hence  not  even  a  negative  reac- 
tion is  of  any  worth." 

Salkowski,®  and  Hess  and  Saxl  ^  discovered  that  in  the  urine 
of  cancer  patients  certain  alcohol-precipitable  nitrogenous  sub- 
stances are  increased.  Tests,  too  complicated  to  be  of  practical 
utility,  were  at  first  devised  for  the  estimation  of  these  sub- 
stances, but  later  Salkowski  ^^  and  Kojo  proposed  a  simpler 
method,  which,  however,  has  not  been  found  of  dependable 
diagnostic  significance. 

Various  serum  reactions  have  been  proposed.  In  the  last  few 
years  alone  there  have  been  announced  those  of  Brieger,  Abder- 

^  Kaldeek.— F'ien.  med.   Woch.,  1911,  Ixi,  1681. 

'  Pribram.— TFien.  klin.  Woch.,  1911,  xxiv,  No.  35,  1235. 

"  Murachl—Biochem.   Ztschr.,    1912,   xli,   138. 

*  Petersen. — Deutsch.  med.  Woch.,  1912,  xxxviii,  No.  33,  1536. 

*  Greenwald,  Isidor. — Archives  of  Internal  Med.,  1913,  No.  12,  p.  283. 
'Fuhs  and  Lintz. — Jour.  Am.  Med.  Assn.,  June  24,  1911,  p.  1882. 
'Verbryeke,  J.  Eussell,  Jr.— Med.  Rec,  Oct.  28,  1911,  p.  876. 

« Salkowski.— BerZ.  Min.  Woch.,  1910,  slvii,   1746. 

'  Hess  and  Saxl. — Beitrdge  sur  Carcinomforschung,  Heft.   II. 

"  Salkowski.— Beri.  klin.   Woch.,   1910,  xlvii,  2297. 


DIAGNOSIS  193 

halden,  Preund  and  Kaminer,  von  Dungern,  Ascoli  modified 
bj  Kraus,  and  of  other  investigators  of  less  prominence. 

After  a  cancer  has  existed  for  a  variable  time,  certain  changes 
in  the  blood  are  noticeable,  but  just  what  these  changes  are,  and 
the  relation  they  bear  to  the  disease  under  investigation,  has 
not  been  clearly  worked  out.  Indeed  they  do  not  appear  to  be 
present  in  every  case  of  cancer,  and  a  blood  examination,  even 
in  an  advanced  case,  may  sometimes  show  a  fairly  normal  pic- 
ture. 

In  the  majority  of  patients,  particularly  with  cancers  whose 
cells  show  a  tendency  to  degenerative  changes,  anemia  is  found. 
But  this  is  not  distinctive  of  malignant  disease,  for  it  is  found 
in  many  other  conditions  bearing  no  relation  to  cancerous 
growths,  as  well  as  in  non-malignant  tumors,  especially  in  large 
uterine  fibroids  with  their  tendency  to  degeneration. 

There  appears  to  be,  therefore,  nothing  specific  of  cancer  in 
these  changes,  and  they  would  appear  to  depend  on  various  inci- 
dental causes  and  not  on  the  presence  of  malignant  cells. 

In  general  it  may  be  said  that  we  find  in  cancer  a  progressive 
anemia — a  gradual  decrease  in  the  total  number  of  red  blood 
cells,  and  a  more  or  less  marked,  and  often  variable,  leukocy- 
tosis. Concurrently  with  these  changes  we  find  a  reduction  in 
the  hemoglobin — often  to  a  very  marked  extent.  Some  inves- 
tigators indeed  have  claimed  that  this  reduction  in  the  hemo- 
globin is  found  so  early  in  the  disease  as  to  be  of  value  in  differr 
ential  diagnosis. 

In  more  recent  years  the  blood  serum  of  cancer  patients  has 
been  made  the  subject  of  study  in  an  attempt  to  demonstrate 
therein  specific  antibodies  or  ferments.  Perhaps  the  better 
known  of  such  reactions  are  those  of  Freund  and  Kaminer,  of 
von  Dungern  and  of  Abderhalden. 

Working  on  the  principle  that  the  blood  serum  of  a  normal 
individual  has  the  power  to  dissolve  cancer  cells,  while  the 
serum  of  a  patient  suffering  from  cancer  lacks  this  power, 
Freund  and  Kaminer  have  established  a  cytolytic  reaction. 
Ten  drops  of  the  patient's  serum,  to  which  one  drop  of  .5  per 
cent,  sodium  fluorid  has  been  added,  are  mixed  with  one  drop 
of  an  emulsion  of  cancer-cells.  The  mixture  is  placed  in  the 
incubator  for  24  hours  and  then  examined  microscopically. 
Should  the  serum  used  be  that  of  a  cancer  patient,  no  change  is 
found,  but  if  the  serum  has  been  taken  from  a  healthy  indi- 
vidual the  number  of  cells  is  found  to  be  materially  reduced. 

The  method  of  von  Dungern  is  comparable  to  the  Wasser- 
mann  reaction  for  syphilis.  In  applying  it  to  cancer  diagnosis 
the  antigen  used  is  made  either  from  cancer-cells  ground  fine 


194.  THE    CANCER    PROBLEM 

and  extracted  with  20  volumes  of  acetone,  or  from  human 
blood,  preferably  that  obtained  from  a  patient  suffering  from 
general  paralysis.  Von  Dungern  prefers  the  latter  method,  in 
the  use  of  which  he  has  claimed  over  90  per  cent,  positive  reac- 
tions in  cancer  patients. 

The  serodialyzation  test  of  Abderhalden  has  more  recently 
been  applied  to  cancer.  Abderhalden  believes  that  the  blood 
serum  of  pregnant  women  contains  specific  ferments  which 
have  the  power  to  digest  placental  cells.  Other  workers  have 
endeavored  to  prove  the  existence  of  ferments  in  the  serum  of 
cancer  patients  which  give  them  the  power  to  digest  cancer 
cells.  The  work  is  still  in  an  experimental  stage,  and  no 
definite  conclusions  can  be  drawn. 

It  is,  of  course,  highly  probable  that  the  metabolism  is  dis- 
turbed in  cancer,  and  that  the  fluids  of  the  body  may  be  differ- 
ent from  the  normal;  such  changes,  however,  if  present,  must 
be  so  subtle  as  to  have  escaped  observation.  'Not  one  of  the 
proposed  tests  can  be  relied  upon.  They  are  all  non-specific 
and  inconstant  for  cancer.  Hence  examination  for  the  purposes 
of  diagnosis  is  still  almost  entirely  restricted  to  examination  of 
the  tumor  or  ulcer  itself. 

SUMMARY 

The  study  of  the  clinical  course  of  cancer  and  the  difficulties 
involved  in  making  a  reliable  diagnosis  cannot  fail  to  empha- 
size the  importance  of  giving  the  patient  the  benefit  of  the 
doubt,  on  the  positive  as  well  as  on  the  negative  side. 

One  or  more  symptoms  should  not  be  relied  upon  in  making 
a  positive  diagnosis  of  malignancy.  Unless  the  clinical  picture 
is  absolutely  convincing,  especially  in  cases  involving  extensive 
surgery,  microscopic  study  should  be  resorted  to. 

In  the  presence  of  a  clear-cut  clinical  picture  of  malignancy, 
involving  radical  surgery,  a  negative  microscopic  examination 
should  not  be  accepted.  In  many  recorded  instances,  as  in 
Case  V,  p.  200,  malignancy  has  been  discovered  only  after  re- 
peated sections  have  been  examined. 

No  reliable  serodiagnostic  test  for  cancer  has  yet  been  pro- 
posed. 


CHAPTEK   III 
POSSIBLE   ERRORS   IN   DIAGNOSIS 


The  frequency  of  over-  and  under-diagnosis  has  been  empha- 
sized by  several  writers.  The  fullest  statistics  have  been  com- 
piled from  the  London  hospitals  by  Bashford,^  as  given  in  the 
following  figures  and  table : 

''Out  of  10,532  cases  of  cancer  treated  in  hospitals,  i.  e., 
under  the  most  favorable  circumstances  for  diagnosis,  1,801 
were  not  diagnosed  as  cancer  from  clinical  evidence  alone. 
Out  of  9,488  cases  treated  as  cancer,  757  were  not  suffering 
from  the  disease.  The  following  table  illustrates  the  relative 
proportions  in  which  the  disease  was  diagnosed  in  different 
sites  of  the  body  according  to  their  accessibility  to  complete 
physical  examination. 

"The  errors  of  diagnosis  in  general  practice  are  probably 
not  less  than  in  hospitals,  although,  of  course,  no  direct  com- 
parison is  possible  between  hospital  patients  and  the  general 
population." 

Analysis  of  the  Cases  of  New  Growths  Reported  by  the  Hospital  Authorities 
{Microscopical  Examination  has  been  made  in  all  Cases),  1904-09,  all  Ages 


Malignant  New  Growtha 

Wrongly 

Correctly- 
diagnosed 

Not 
diagnosed 

diagnosed  as 
cancer 

Accessible                   

5,854 
1,555 
1,322 

567 
945 

289 

438 

Inaccessible            

159 

Intermediate 

160 

Total 

8,731 

1,801 

757 

91.1% 

62.2% 
82.0% 

93.0% 
90.7% 
89.2% 

8.9% 
37.8% 
18.0% 

Intermediate 

Accessible  .                 

7.0% 

Inaccessible   .               

9.3% 

Intermediate    .                        

10.8% 

'  Bashf  ord,  E.  F. — ' '  An  Address  on  Cancer  in  Man  and  Animals, ' '  The 
Lancet,  Lond.,  Sept.  4,  1909,  II,  p.  691. 

195 


196  THE    CANCER    PROBLEM 

The  diagTiosis  and  treatment,  as  cancer,  of  tumors  which  are 
■ultimately  found  to  have  been  of  a  different  nature,  has  an- 
other interest.  Of  the  cases  operated  on  or  examined  at  autopsy 
in  the  above  table,  as  many  as  757  were  not  cancer.  There  is 
no  reason  why  the  relative  proportion  of  cases  wrongly  treated 
as  cancer  should  be  less  in  those  refusing  operation  after  clin- 
ical diagnosis.  This  explains  very  largely  the  extravagant 
claims  made  in  certain  quarters  of  curing  cancer  without  the 
knife. 

In  the  following  pages  I  have  endeavored  to  point  out,  by 
illustrative  cases  from  my  own  experience,  possible  errors  which 
may  be  made  in  the  diagnosis  of  cancer  of  some  of  the  regions 
most  frequently  involved. 

HEAD 

Case  I.  Indurated  mass  in  scalp,  simulating  malignancy, 
caused  by  foreign  hody. — G.  S.,  female,  aged  50.  Admitted  to 
my  service  at  the  New  York  Polyclinic  Medical  School  and 
Hospital,  February  14,  1908.  She  gave  the  history  of  having 
first  noticed,  two  years  before,  a  small  tumor  on  the  top  of  the 
head.  A  few  days  after  detection  a  scab  formed  over  the  center 
of  the  mass,  and  when  this  was  removed  there  was  a  free  dis- 
charge of  purulent  material,  after  which  the  slight  soreness 
which  had  been  present  disappeared.  The  indurated  area  per- 
sisted, however,  and  from  time  to  time  a  number  of  physicians 
in  turn  were  consulted.  The  majority  of  those  who  examined 
it  pronounced  it  "malignant,"  and  advised  the  removal  of  the 
entire  area  under  general  anesthesia.  The  patient  refused  to 
consent. 

Examination  when  I  first  saw  her  revealed  a  tumor  of  the 
scalp  about  the  size  of  a  silver  dollar,  a  little  to  the  left  of  the 
center  of  the  occiput.  Toward  the  center  of  this  was  a  crater- 
like  elevation  in  which  was  an  opening.  At  the  bottom  of  this 
opening  could  be  seen  a  dark  object.  From  the  history  of  the 
case  and  from  examination,  the  condition  appeared  to  me  to 
be  more  of  an  inflammatory  character,  caused  by  a  foreign  body 
of  some  kind,  rather  than  malignant.  I  therefore  advised  re- 
moval of  the  tumor  under  local  anesthesia.  The  entire  mass 
was  removed,  the  wound  closed,  and  a  dry  dressing  applied. 
Healing  by  primary  union  was  prompt,  and  the  patient  has  had 
no  further  trouble  in  this  regard. 

Examination  of  the  mass  revealed  part  of  the  tooth  of  a 
comb,  which  had  become  embedded  in  the  tissues  of  the  scalp.. 


POSSIBLE    ERRORS    IN    DIAGNOSIS  197 

giving  rise  to  chronic  irritation,  with  subsequent  inflammation 
and  induration. 

Careful  microscopic  examination  showed  no  malignancy. 

The  points  to  be  emphasized  in  this  case  are: 

1.  The  clinician  must  ever  be  watchful  for  the  unusual  and 
unexpected. 

2.  Chronic  irritation  alone,  even  in  those  of  the  so-called 
cancerous  age,  does  not  always  initiate  a  malignant  process. 

3.  The  importance  of  finer  discrimination  in  diagnosis. 
Despite  the  stationary  character  of  the  growth,  the  absence  of 
pain,  and  the  presence  of  a  palpable  foreign  body,  a  number  of 
physicians  had  pronounced  the  condition  malignant. 

4.  The  promptness  with  which  the  tissues  healed  in  the 
region  where  chronic  irritation  had  existed  for  over  two 
years. 

Case  IL  Epithelioma  of  the  scalp,  iyivolving  external  table 
of  skull  and  diploe. — A.  M.,  female,  age  given  as  sixty-five,  in 
reality  nearly  seventy-five.  Admitted  to  my  service  at  the 
ISTew  York  Skin  and  Cancer  Hospital,  January  16,  1908.  Fif- 
teen years  before  admission  the  patient  had  first  noticed  a  small 
"lump"  on  the  top  of  the  head.  This  had  grown  slowly,  but 
had  given  little  trouble  until  a  year  before,  when  it  began  to 
grow  very  rapidly,  to  ulcerate,  to  bleed  freely,  and  to  cause 
considerable  pain.  She  then  went  to  the  dispensary  of  one  of 
the  hospitals  of  the  city,  where  for  a  year  she  was  given  anti- 
syphilitic  treatment.  The  conditions  grew  steadily  worse 
despite  this  treatment,  whereupon  she  was  referred  to  me. 

Examination  revealed  an  ulcerating  area  of  the  scalp  about 
four  inches  square.  Upon  operation  this  was  found  to  involve 
not  only  the  scalp,  but  the  external  table  of  the  skull  and  the 
diploe.  The  entire  area  covered  by  the  growth,  together  with  a 
free  margin  of  healthy  tissue,  was  removed.  The  external 
table  of  the  skull,  with  the  corresponding  diploe,  over  an  area 
about  two  inches  square,  was  chiseled  away.  The  wound  was 
packed.  It  was  intended  to  perform  a  plastic  operation  after 
healthy  granulations  were  formed,  but  this  the  patient  obsti- 
nately refused  to  allow.  She  left  the  hospital  at  the  end  of 
three  weeks,  with  the  wound  granulating  around  the  edges. 

On  February  21,  1908,  the  patient  was  admitted  to  my 
service  at  the  N^ew  York  Polyclinic  Medical  School  and  Hos- 
pital, remaining  under  care  for  a  number  of  weeks.  Later  she 
was  treated  in  my  dispensary  service  at  the  same  institution. 
Gradually  the  entire  area  closed  in  and  rounded  out,  so  that 
new  skin  formed  and  the  tissues  underneath  it  seemed  to  cor- 
respond very  largely  to  the  structure  of  the  normal  scalp ;  even 


198  THE    CANCER    PROBLEM 

the  bone  of  the  external  table  of  the  skull  appeared  to  be  repro- 
duced. 

The  pathological  report  was  "epithelioma  basocellare,  of  the 
papillomatous  type." 

Patient  well  Avhen  lost  sight  of  four  years  afterward. 

This  case  is  interesting  because  of: 

1.  The  extent  of  the  malignant  process  and  the  involvement 
of  the  bone. 

2.  The  complete  recovery  in  a  woman  of  advanced  age. 

3.  The  regeneration  of  the  tissues,  or  their  replacement  by 
healthy  tissue,  without  the  intervention  of  plastic  surgery. 

4.  The  mistaking  of  an  epithelioma,  which  had  been  prac- 
tically stationary  for  fourteen  years,  and  which  had  then  sud- 
denly taken  on  rapid  growth,  for  syphilis,  and  the  administra- 
tion of  anti-syphilitic  treatment  for  a  year,  despite  the  con- 
tinued development  of  the  process. 

Case  III.  Intracranial  tumor — epidural  aberrant  thyroid. — 
M.  S.,  female,  aged  sixty-two,  married,  native  of  Nova  Scotia. 
First  consulted  me  in  October,  1906.  Examination  revealed  a 
tumor,  about  the  size  of  an  orange,  on  the  left  of  the  head. 
This  had  gradually  developed,  according  to  the  history,  within 
three  years,  but  had  given  no  symptoms  other  than  occasional 
severe  headache.  The  eyes  were  slightly  more  prominent  than 
normal,  there  was  some  pallor,  suggestive  of  the  early  stage  of 
cachexia,  and  the  patient  was  very  nervous.  Otherwise  she  was 
in  fair  general  condition.  On  the  right  side  a  goiter  about  the 
size  of  a  hen's  egg  could  be  noted. 

Examination  of  the  tumor  showed  it  to  be  not  adherent  to 
the  skin,  and  to  come  from  the  external  table  of  the  skull  or 
from  within.  A  bony  ridge  could  be  felt  around  its  base.  The 
consistency  of  the  tumor  was  masked  by  the  tense  pericranium 
and  by  the  scalp  overlying.  Xo  pulsation  of  the  brain  could  be 
felt.  I  made  the  diagnosis  of  intracranial  tumor,  and  advised 
an  exploratory  operation. 

Previous  to  coming  to  New  York  the  patient  had  consulted 
three  physicians.  Two  of  these  made  the  diagnosis  of  sebaceous 
cyst,  and  offered  to  remove  the  tumor  in  their  offices  under  local 
anesthesia.  The  third  believed  it  to  be  a  more  serious  condi- 
tion, but  being  unwilling  to  operate  himself  he  advised  her  to 
consult  with  some  one  who  could  cope  with  whatever  it  might 
prove  to  be.     She  then  came  to  New  York. 

The  patient  was  admitted  to  my  service  at  the  New  York 
Polyclinic  Medical  School  and  Hospital,  October  10,  1906. 
She  was  presented  before  the  class  in  that  institution,  consisting 
of  about  fifty  physicians,  all  of  whom  were  given  an  oppor- 


POSSIBLE    ERRORS    IN    DIAGNOSIS  199 

tunity  to  examine  the  case  and  make  a  diagnosis.  Not  one 
would  agree  that  the  tumor  was  intracranial,  the  consensus  of 
opinion  favoring  the  diagnosis  of  sebaceous  cyst.  Hematoma, 
lipoma,  fibroma,  dermoid  cyst,  carcinoma,  and  sarcoma  were 
some  of  the  diagnoses  offered. 

Believing  it  to  be  intracranial,  I  made  an  exploration  and 
found  that  the  probe  passed  down  through  the  wound,  straight 
into  the  skull.  A  small  piece  of  the  tumor  was  removed  for 
examination,  the  strictest  precautions  of  asepsis  being  taken, 
and  the  wound  closed.  The  situation  was  explained  to  the  fam- 
ily and  the  gravity  of  the  condition  made  clear.  It  was  decided 
to  give  the  patient  the  chance  offered  by  operation.  Accord- 
ingly, I  operated  two  weeks  later.  The  tumor,  which  was  the 
size  of  an  orange  externally,  and  almost  as  large  internally,  was 
removed.  The  dura  was  greatly  thinned  over  the  indented  por- 
tion of  the  cerebrum.  The  hemorrhage  was  severe,  but  was 
controlled  largely  by  pressure.  The  patient  failed  to  rally, 
despite  the  use  of  the  various  methods  of  stimulation,  including 
infusion,  and  died  within  two  hours  after  the  operation. 

Dr.  E.  M.  Jeffries,  Pathologist  to  the  IsTew  York  Polyclinic 
Medical  School  and  Hospital,  gave  the  following  report  of  post- 
mortem examination :  "Tumor  of  dura  mater  covering  a  por- 
tion of  the  left  cerebrum.  It  was  three  and  one-half  inches  in 
diameter,  circular,  and  on  the  outer  surface  of  the  dura.  Its 
upper  edge  bordered  on  the  median  line  about  three-quarters 
of  an  inch  posterior  to  the  middle.  The  growth  was  sharply 
defined  upon  the  dura,  but  did  not  manifest  itself  on  the  inner 
surface.  The  brain  tissue  beneath  was  depressed  for  an  area 
three  and  a  half  by  four  and  a  half  inches.  There  was  no  evi- 
dence of  absorption  or  inflammation  of  brain  tissue. 

"Microscopically  the  growth  is  somewhat  doubtful  in  charac- 
ter. Judging  from  the  clinical  aspect  it  should  be  endotheli- 
oma ;  but  sections  of  it  would  serve  very  well  for  demonstrating 
thyroid  tissue.  Structurally  it  is  an  adenoma  suggesting  aber- 
rant thyroid." 

Dr.  James  Ewing,  Professor  of  Pathology,  Cornell  Univer- 
sity Medical  College,  and  Dr.  William  Elser,  Pathologist  to  the 
New  York  Hospital,  verified  Dr.  Jeffries'  diagnosis  with  refer- 
ence to  the  appearance  of  thyroid  tissue,  pronouncing  it  aber- 
rant or  "wandering"  thyroid. 

TONGUE 

Case  IV.  Gumma  of  tongue. — J.  T.,  male,  aged  thirty-one, 
admitted  to  the  New  York  Skin  and  Cancer  Hospital  June  19, 


200  THE    CANCER    PROBLEM 

1907.  Negative  luetic  history  given.  Nine  months  before 
admission  patient  noticed  a  small  "sore"  at  base  of  tongue, 
near  the  center  of  dorsum.  During  my  absence  from  town  the 
diagnosis  of  cancer  of  the  tongue  was  made  by  six  different 
doctors.  When  I  returned  the  patient  was  on  the  table,  ready 
to  be  anesthetized  for  operation  for  removal  of  the  tongue.  I 
made  an  examination  and  found  a  deep  ulceration,  about  one 
inch  wide,  extending  backward  from  the  posterior  two-thirds  of 
the  dorsum  of  the  tongue  to  the  epiglottis.  The  edges  were 
irregular  and  elevated,  and  the  floor  uneven  and  coated.  The 
edges  were  soft  and  friable.  Cervical  and  supraclavicular 
glands  were  enlarged.  I  refused  to  operate,  and  immediately 
placed  the  patient  upon  antisyphilitic  medication,  with  the  re- 
sult that  the  ulceration  completely  disappeared.  The  correct- 
ness of  my  diagnosis  was  further  shown  by  the  pathological 
reports  from  Dr.  Martha  Wollstein,  of  the  Rockefeller  Insti- 
tute, and  Dr.  H.  H.  Janeway,  Assistant  Pathologist  to  the  New 
York  Skin  and  Cancer  Hospital,  both  of  whom  rendered  nega- 
tive reports  as  far  as  cancer  was  concerned,  each  suggesting 
quiescent  tuberculosis  or  syphilis  as  the  probable  condition. 
No  tubercle  bacilli  were  found. 

Case  V.  Epithelioma  of  tip  of  tongue,  early  stage. — 
L.  J.  R.,  male,  aged  41.  The  small  nodule,  together  with  a 
w'edge-shaped  section  of  apparently  healthy  tissue  surrounding 
it,  one  inch  long,  removed  from  median  line  of  tongue.  Care- 
ful microscopic  examination  was  made,  not  only  of  the  nodule 
itself,  but  of  sections  taken  along  the  healthy  tissue.  Micro- 
scopic examination  of  the  nodule  verified  the  clinical  diagnosis. 
No  cancer  cells  were  foimd  in  the  remainder  of  the  wedge- 
shaped  section  of  tissue  until  nearly  the  very  apex  of  the  wedge 
was  reached.  There  a  nest  of  suspicious  cells  was  found,  and  a 
day  later  a  longer  angle  was  made  by  the  removal  of  another 
small  section  at  the  apex  of  the  wedge-shaped  incision. 

Had  not  a  very  thorough  microscopic  examination  been  made 
in  this  case,  the  removal  of  the  nodule,  with  the  wedge-shaped 
section  of  apparently  healthy  tissue,  might  have  been  consid- 
ered sufficient.  Recurrence  would  have  been  inevitable.  As  it 
was,  the  discovery  of  the  nest  of  cancer  cells  at  the  apex  of  the 
wedge-shaped  piece  of  tissue  removed,  and  the  wider  dissection, 
have  been  followed  by  freedom  from  recurrence  for  over  five 
years. 

Case  VI.  Carcinoma  of  tongue,  advanced  stage. — E.  S., 
male,  aged  42.  Absolutely  negative  history  regarding  lues. 
Patient  had  been  an  excessive  smoker,  always  holding  the  cigar 
on  the  right  side  of  the  mouth.    A  number  of  years  previous  to 


POSSIBLE    ERRORS    IN    DIAGNOSIS  201 

consulting  me  he  had  first  noticed  a  small  sore  on  the  dorsum  of 
the  tongue,  half  an  inch  from  the  right  side  and  one  and  a  half 
inches  back.  This  would  come  and  go,  and  was  treated  by 
diverse  methods — nitrate  of  silver,  antisyphilitic  treatment  (a 
positive  diagnosis  of  syphilis  having  been  made  by  the  physi- 
cian then  in  charge),  X-ray,  mixed  treatment,  etc.  The  growth 
was  cut  into  by  a  dermatologist  for  the  purpose  of  taking  a 
section  for  microscopic  study,  and  the  report  rendered  that  it 
was  non-malignant.  After  going  from  one  physician  to  another 
without  benefit,  the  patient  consulted  Dr.  L.  Duncan  Bulkley, 
by  whom  he  was  referred  to  me.  The  mouth  was  in  a  very  fetid 
condition  and  the  glands  of  the  right  side  of  the  neck  were 
involved.  The  disease  was  too  far  advanced  for  reasonable  hope 
of  cure,  but  not  too  advanced  for  operative  procedure  with  the 
hope  of  relieving  sufl^ering  and  prolonging  life. 

The  involved  glands  were  removed  and,  at  a  subsequent 
operation,  the  tongue  was  completely  excised.  The  patient 
gained  in  flesh  and  strength  and  was  able  to  attend  to  his  busi- 
ness for  months.  Recurrence  finally  took  place  in  the  neck,  the 
patient  was  placed  on  the  Enzyme  Treatment  (Case  N^o.  Y6),^ 
and  died  one  year  after  I  first  saw  him. 

An  early  correct  diagnosis  and  the  institution  of  the  proper 
treatment  should  have  put  an  effectual  stop  to  the  malignant 
process  in  this  case  as  it  did  in  Case  V.  Cutting  into  the  tumor 
doubtless  materially  lessened  the  patient's  chances  of  cure. 

BREAST. 

Case  VII.  Lipoma,  between  pectoralis  major  and  minor 
muscles,  extending  up  under  the  clavicle,  and  pushing  the  pec- 
toralis major  and  the  breast  forward. — Female,  aged  34.  The 
growth  gave  the  appearance  of  tumor  of  the  breast,  and  was  so 
diagnosed  by  a  number  of  physicians,  who  thought  it  was  prob- 
ably malignant.  If  it  had  been  malignant,  removal  of  the  en- 
tire breast  would  have  been  necessary.  It  proved  to  be  a  multi- 
lobular lipoma,  weighing  three-quarters  of  a  pound.  Eemoved, 
without  mutilation. 

Case  VIII.  Lipoma. — -This  patient,  female,  30  years  of 
age,  was  presented,  for  diagnosis  of  tumor  of  breast,  to  the  sur- 
gical matriculates  of  the  New  York  Polyclinic  Medical  School 
and  Hospital.  The  majority  who  examined  her  pronounced  the 
condition  probably  malignant,  and  advised  removal  of  the 
breast.  This  diagnosis  and  advice  were  not  accepted.  The 
tumor  was  removed  by  the  author  through  an  incision  under 
the  breast,  and  proved  to  be  a  small  lipoma. 

'  Bainbridge. — See  General  Bibliography. 


202  THE    CANCER    PROBLEM 

Case  IX.  Lipoma:  fihroadcmata. — Woman,  32  years  of 
age,  gave  a  history  of  injury  to  left  arm,  and  presented  a  tumor 
{lipoma)  of  left  shoulder,  and  multiple  tumors  (fibroadeno- 
mata)  of  left  breast,  with  retraction  of  both  nipples.  Pain  in 
breast  for  several  months.  The  history  of  pain,  and  the  retrac- 
tion of  the  nipples,  might  easily  have  led  to  the  diagnosis  of 
malignancy  and  to  the  removal  of  the  breast.  Such  advice  had 
been  urged  by  some.  Upon  interrogation  it  was  learned  that 
the  retraction  of  the  nipples  was  congenital.  The  tumors  were 
removed,  and  proved  to  be  non-malig-naut. 

Case  X.  FibroUpoma. — Female,  54  years  of  age.  Tumor 
in  left  axilla,  extending  to  upper  margin  of  left  breast.  Had 
been  growing  for  five  years,  more  rapidly  of  late,  and  had  be- 
come painful.  Nipple  of  left  breast  retracted.  The  cancerous 
age ;  a  mass  in  the  axilla,  extending  to  the  breast ;  retraction  of 
the  nipple  on  the  same  side ;  rapidity  of  growth  of  a  previously 
slow-growing  tumor ;  pain  and  discomfort  in  tumor — presented 
a  picture  strongly  simulating  malignancy.  Yet  the  tumor,  upon 
removal,  proved  to  be  fibrolipoma.  The  pain  was  doubtless 
partly  psychic.  In  the  presence  of  dense  connective  tissue,  a 
fatty  tumor  in  process  of  development  may  cause  sufficient  ten- 
sion to  give  rise  to  pain  and  discomfort — leading,  at  times,  to 
the  clinical  diagnosis  of  malignancy. 

Case  XI.  Necrosis  of  Rib,  with  Abscess. — Female,  aged  21 
years.  History  of  injury  to  neighborhood  of  sixth  costal  carti- 
lage of  left  side,  just  under  the  breast,  where  she  had  pricked 
herself  with  a  large  knitting  needle.  An  abscess  formed,  which 
was  poulticed  for  a  week.  Abscess  returned,  with  a  resulting 
sinus  which  persisted  to  time  of  examination  (about  six 
months).  Had  had  two  operations^  the  sinus  being  opened  and 
the  bone  scraped.  Consulted  me  after  two  physicians  had  pro- 
nounced the  condition  malignant.  Careful  examination  showed 
necrosis  of  the  sixth  rib  and  costal  cartilage,  with  an  abscess  on 
the  ribs.  Incision  below  breast,  breast  lifted  up,  abscess  evacu- 
ated, and  diseased  bone  removed.  The  condition  proved  to  be 
localized  tuberculosis,  with  no  evidence  of  malignancy. 

Case  XII.  Lumpy  condition  in  both  breasts,  with  an  in- 
definite mass  in  lower  outer  quadrant  of  right  breast. — Female, 
3Y  years  of  age.  No  distinct  retraction  of  nipple,  no  enlarge- 
ment of  axillary  glands.  Diagnosis  of  malignancy  had  been 
made  by  two  physicians,  who  advised  against  immediate  opera- 
tion because  of  patient's  extremely  neurasthenic  condition. 
Growing  steadily  worse,  she  consulted  another  physician,  who 
frankly  told  her  she  had  cancer  of  both  breasts.    He  treated  her 


POSSIBLE    ERRORS    IN    DIAGNOSIS  203 

for  some  weeks  with  a  cancer  extract.  She  was  also  given  gal- 
vanism for  about  six  weeks.  She  then  came  to  me.  Examina- 
tion revealed  intestinal  stasis,  and  this  lumpy  condition  in  the 
breasts.  I  told  her  she  had  no  cancer,  but  she  insisted  upon 
being  operated  upon,  and,  to  satisfy  her,  I  removed  two  lumps 
from  one  breast.  These  proved  to  be  benign.  She  was  placed 
upon  the  usual  non-surgical  treatment  for  chronic  intestinal 
stasis,  and  was  told  to  wear  breast  supporters.  The  lumpy  con- 
dition of  the  breasts  cleared  up  completely,  without  operative 
interference. 

Case  XIII.  Obstruction  of  Mammary  Gland  Ducts. — Boy, 
between  12  and  13  years  of  age.  Came  into  my  clinic  at  the 
New  York  Polyclinic  Medical  School  and  Hospital  almost  cry- 
ing, with  a  frightened  look  on  his  face,  as  if  something  terrible 
were  impending.  His  mother  had  consulted  me  a  few  months 
before  with  cancer  too  far  advanced  for  anything  to  be  done 
surgically.  She  was  treated  with  palliative  measures  for  some 
time,  and  finally  died.  The  boy  had  discovered  a  swelling  be- 
low the  nipple  of  each  of  his  breasts,  more  marked  in  the  left. 
He  came  to  the  clinic  with  the  firm  belief  that  he  had  cancer. 
Friends  had  told  him  they  were  sure  he  had  his  mother's 
trouble.  Careful  examination  revealed  simply  obstruction  of 
the  gland  ducts,  as  sometimes  found  in  the  young.  The  condi- 
tion was  relieved  by  application,  for  a  few  weeks,  of  belladonna 
ointment. 

Case  XIV.  Sarcoma. — Female,  aged  55  years.  Three 
years  before  noticed  a  small  swelling,  hard  and  nodular,  in  left 
axilla.  Her  physician  told  her  to  leave  it  alone.  A  month  later 
an  abscess  developed,  which  was  opened  and  treated  for  two 
weeks  without  improvement,  and  with  the  formation  of  fistulse, 
which  persisted  despite  treatment.  After  a  succession  of  opera- 
tions the  mass  in  the  breast  continued  to  increase  until  it  in- 
volved the  left  breast  and  almost  the  entire  left  chest  wall.  The 
condition  was  pronounced  by  several  physicians  irremovable 
sarcoma  of  the  chest  wall.  By  one  she  was  treated  for  a  time 
with  a  serum,  without  benefit.  She  was  then  given  morphin 
and  bromids  and  practically  abandoned  to  her  fate.  Her  suffer- 
ing became  so  intense  that  Dr.  I.  A.  Stoloff  was  called  in  by  the 
family  with  the  request  that  he  euthanize  her.  He  called  me  in 
consultation,  and  the  patient  was  sent  to  the  hospital.  The 
tumor  in  the  breast  proved  to  be  a  tuberculous  abscess,  with  no 
evidence  of  malignancy.  I  cleared  out  all  the  tuberculous  tis- 
sue, which  required  an  extensive  operation.  The  patient  made 
an  uneventful  recovery,  and  is  well  to-day. 


204  THE    CANCER    PROBLEM 

ABDOMEN. 

Not  SO  many  years  have  elapsed  since  the  abdominal  cavity 
was  a  veritable  terra  incognita.  In  many  respects,  and  to  some 
physicians  and  surgeons,  it  is  still  a  world  of  mystery.  It  has 
•furnished  a  convenient  hiding  place  for  many  of  the  budgets 
of  diagnostic  error  which  have  made  so  large  a  part  of  the  his- 
tory of  medicine  and  surgery.  And  yet,  within  its  hidden  re- 
cesses have  been  performed  some  of  the  most  brilliant  and  dar- 
ing feats  of  surgery. 

With  the  general  progress  in  medicine  and  surgery  which 
has  marked  the  last  quarter-century,  modern  methods  of  diag- 
nosis, chemical,  bacteriological,  physical,  and  electrical,  have 
brought  us  into  intimate  acquaintance  with  this  region  and  with 
the  diseases  to  which  its  contents  are  subject,  enabling  us,  with 
a  fair  degree  of  accuracy,  to  predict  what  will  be  revealed  by 
operation.  In  many  cases,  however,  it  is  impossible,  by  any 
external  diagnostic  methods,  to  ascertain  the  exact  conditions 
to  be  dealt  with,  and  consequently  we  are  unable  to  apply  effec- 
tual remedial  agencies.  In  such  cases  exploratory  laparotomy 
comes  into  requisition. 

The  cases  given  below  emphasize  the  importance  of  explora- 
tory laparotomy,  not  as  a  last  resort,  but  as  an  early  means  of 
making  an  absolutely  correct  diagnosis,  not  only  as  to  the  pres- 
ence and  extent,  but  as  to  the  site,  of  cancer.  The  most  telling 
arguments  in  favor  of  opening  the  abdomen  and  of  seeing  and 
feeling  the  actual  state  of  affairs,  are  cases  in  which  patients 
have  been  allowed  to  go  untreated,  or  to  be  incorrectly  treated, 
until  it  is  too  I^te  for  curative  surgical  intervention ;  and  cases 
in  which,  through  inexperience,  perhaps,  the  surgeon  is  unable 
to  make  the  correct  diagnosis,  even  when  the  abdomen  is  opened. 
More  frequent  resort  to  exploratory  laparotomy,  and  the  de- 
velopment of  skill  in  differential  diagnosis  when  this  is  done, 
would  be  the  means  of  saving  many  lives,  and  of  prolonging  the 
life-span  of  many  more. 

The  following  cases  are  selected  to  illustrate  six  of  the  more 
common  sources  of  error  in  the  diagnosis  of  abdominal  cancer. 

Type    I. 

Cases  Diagnosed  as  Cancer,  with  no  Cancer  Present. — This 
is  not  an  uncommon  class  of  cases,  for  the  reason  that  there  are 
so  many  conditions  which,  without  exploratory  laparotomy,  may 
be  easily  mistaken  for  cancer  of  some  portion  of  the  abdominal 
contents.     The  real  condition  may  easily  be  amenable  to  surgi- 


POSSIBLE    ERRORS    IN    DIAGNOSIS  205 

cal  intervention  and  cure,  yet  the  patient  may  be  considered  in- 
curable and  operation  of  too  little  avail  to  warrant  the  supposed 
contingent  risks.  The  following  is  a  list  of  some  of  the  condi- 
tions, the  symptoms  of  which  may  lead  to  the  diagnosis  of 
abdominal  cancer : 

1.  Appendicitis  with  abscess  formation  (Case  XV,  Type  1 ). 

2.  Tuberculosis  of  kidney,  liver,  spleen,  etc.  (Case  XVI, 
Type  I). 

3.  "Stomach  trouble" — healed  ulcer,  with  pyloric  stenosis 
(Case  XVII,  Type  I). 

4.  Stone  in  kidney, with  cachexia,  etc.  (Case  XVIII,Type  I ). 

5.  Gall-stones. 

6.  Apparent  tumors  of  stomach.  (Kemp.)  Conditions 
mistaken  for : 

(a)  Prolapse  of  left  lobe  of  liver. 

(b)  Pulsating  aorta. 

(c)  Thickening  of  abdominal  muscles  (recti). 
Gastroptosis  is  usually  associated  with  these  conditions;  con- 
sequently there  is  generally  a  long  history  of  emaciation. 

10.  Simple  adhesions  of  the  stomach,  generally  following 
gall-bladder  disease,  gastric  ulcer,  or  localized  peritonitis. 

11.  Syphilis,  according  to  Kemp,  unless  very  careful  ex- 
amination is  made,  may  present  symptoms  which  simulate  car- 
cinoma of  the  stomach.  He  cites  three  cases.  (Case  XIX, 
Type  I,  illustrates  this  point.) 

Kemp's  cases : 

(a)  Sclerosis  of  stomach. 

(b)  Cirrhosis  of  liver. 

(c)  Stenosis  of  pylorus,  due  to  gummatous  tumor,  simulat- 
ing malignancy. 

12.  Aneurysm  of  celiac  axis  simulating  carcinoma  of  py- 
lorus. 

13.  Chronic  gastritis. 

14.  Nervous  gastralgia. 

The  following  cases  illustrate  this  class  of  mistakes : 

Case  XV. — M.  E.  F.,  female,  widow,  aged  56,  ten  children. 

Previous  History. — Two  years  previous  to  consulting  me, 
October  21,  1912,  was  operated  upon  for  right  inguinal  hernia. 
A  large- sinus  formed  in  the  hernial  wound.  When  first  seen 
had  been  losing  flesh  and  strength  for  a  year.  Considerable 
apparent  cachexia.  Large  abdominal  tumor,  which  had  in- 
creased in  size,  occupying  the  center  of  the  abdomen,  seemingly 
connected  with  the  stomach  and  intestine.  This  had  been  diag- 
nosed by  several  as  irremovable  cancer,  and  she  had  been  told 


206  THE    CANCER    PROBLEM 

that  she  was  incurable.  Sought  relief  by  some  form  of  serum 
treatment,  for  this  purpose  going  to  several  dispensaries  and 
hospitals,  from  which  she  was  sent  away  with  no  hope. 

Physical  Examination. — Careful  physical  examination  raised 
a  grave  doubt  as  to  the  presence  of  cancer.  Exploratory  lapar- 
otomy advised. 

Operation,  New  York  Skin  and  Cancer  Hospital,  November 
16,  1912.  A  mass  the  size  of  a  child's  head  was  found  in  the 
lower  portion  of  the  abdomen.  It  was  made  up  of  great  omen- 
tum enveloping  a  large  abscess,  in  the  center  of  which  was  the 
appendix.  The  appendix  was  removed,  adhesions  broken  up, 
and  abscess  drained.  There  was  no  evidence  of  cancer.  The 
sinus  in  the  right  side  led  down  to  an  unabsorbed  stitch,  and 
was  curetted. 

Subsequent  History. — Uneventful  recovery.  The  cachexia, 
which  was  due  to  low-grade  sepsis,  not  cancer,  disappeared. 
January  1,  1914,  perfectly  well  and  strong. 

Case  XVI. — Mrs.  G.  A.  A.,  aged  50.  One  child.  Referred 
by  Dr.  Cora  M.  Ballard,  of  Brooklyn,  February  15,  1909. 

Previous  History. — Pain  of  long  duration  in  left  side,  with 
gradually  growing  tumor  in  same  region.  Loss  of  strength  and 
flesh,  with  chills.  Marked  cachexia.  Urine  negative.  Con- 
sulted a  number  of  physicians  and  surgeons,  some  of  whom 
made  the  diagnosis  of  irremovable  cancer,  involving  kidney, 
spleen,  and  liver.  Dr.  Ballard  was  called  and  doubted  the  utter 
hopelessness  of  the  condition,  and,  in  a  last  effort  for  relief, 
with  no  thought  of  cure,  I  was  called  to  see  the  patient. 

Physical  Examination. — Mass  in  left  upper  quadrant  of 
abdomen,  size  of  liver. 

Diagnosis. — Abscess  of  left  kidney. 

Operation,  New  York  Medical  College  and  Hospital  for 
Women,  February  22,  1909.  Ureteronephrectomy  for  pyelo- 
nephrolithiasis,  with  perinephric  and  priureteral  abscesses. 
Evacuation  of  about  a  quart  of  pus. 

Pathological  Eeport,  Dr.  Louis  Rene  Kaufman. — "Acute 
pyonephritis.  Abscess  of  pelvis  and  kidney,  due  probably  to 
the  Bacillus  coli  communis,  with  multiple  calculi  of  urates  and 
uric  acid. 

"Miliary  abscesses  are  present  in  both  medulla  and  cortex 
among  remnants  of  kidney  tissue,  with  advanced  necrosis  and 
hemorrhage ;  very  little  kidney  substance  is  left  and  none  is 
normal  in  sections  examined." 

Subsequent  History. — Uneventful  recovery.  March  30, 
1910,   a  sinus  formed   in  the   scar,  which  was   curetted.      It 


POSSIBLE    ERRORS    IN    DIAGNOSIS  207 

healed,  but  later  formed  again.  In  November,  1911,  a  new 
sinus  started,  whereupon  the  patient  was  given  an  autogenous 
colon  bacillus  vaccine.     Perfectly  well  ever  since. 

Case  XVII.— W.  H.  B.,  male,  aged  46.  Kef  erred  by  Dr. 
C.  K.  Woods,  of  Hamden,  N.  Y.,  February  12,  1909. 

Previous  History. — "Stomach  trouble"  for  six  years,  grow- 
ing steadily  worse.  For  two  years  vomited  "by  spells."  CofFee- 
ground  material  for  the  past  year.     Loss  of  flesh  and  strength. 

X-ray  Examination,  by  Dr.  Lewis  Gregory  Cole. — "Hour- 
glass contraction  of  stomach,  with  dilatation  of  the  upper  seg- 
ment of  the  hook,  just  above  the  constriction  on  the  lesser 
curvature.  .  .  .  Whether  this  is  from  an  old  scar  or  a  new 
growth  I  do  not  feel  justified  in  stating." 

Diagnosis. — Chronic  indurated  ulcer,  with  probable  malig- 
nant change.  Impossible  to  determine  the  exact  nature  by 
other  means  than  exploratory  laparotomy.  All  other  usual 
diagnostic  methods  employed. 

Operation,  ISTew  York  Polj^clinic  Hospital,  April  5,  1909. 
Large  mass  found  at  pyloric  end  of  stomach,  causing  consider- 
able pyloric  stenosis.  The  diseased  area  was  so  large,  and  the 
glands  so  enlarged  that  if  the  condition  were  malignant  the 
removal  of  the  mass  and  of  the  diseased  glands  was  hardly  pos- 
sible. However,  believing  it  to  be  probably  benign,  it  was  de- 
cided to  resort  to  posterior  gastro-enterostomy. 

Subsequent  History. — Uneventful  recovery.  Marked  gain 
in  flesh  and  strength.  Pains  slowly  disappeared.  Perfectly 
well  and  strong,  January  1,  1914. 

Case  XVIII. — L.  C,  male,  railway  engineer,  aged  69  years. 
First  seen  at  one  of  the  suburban  hospitals.  May  7,  1909. 

Previous  History. — Had  had  stone  in  the  bladder  twenty-five 
years  before.  For  many  months  had  been  slowly  losing  flesh 
and  strength,  with  pain  in  the  abdomen,  and  the  appearance 
of  a  slowly  growing  tumor,  which  was  diagnosed  as  cancer  of 
the  stomach,  involving  the  left  kidney  and  other  abdominal 
organs.  Pronounced  inoperable,  and  patient  sent  to  hospital, 
January  8,  1909,  for  palliative  treatment. 

Physical  Examination. — May  7,  1909.  Markedly  cachectic, 
very  weak  and  emaciated.  Made  the  diagnosis  of  stone  in  the 
kidney,  with  abscess,  but  no  malignancy.  Advised  exploratory 
operation. 

Operation,  May  7,  1909.  Diagnosis  verifled.  Large  stone 
found,  with  abscess  formation  within  and  around  the  left  kid- 


208  THE    CANCER    PROBLEM 

ney,  but  absolutely  no  cancer.  Stone  removed  and  abscess 
drained. 

Subsequent  History. — On  account  of  the  patient's  weakened 
condition,  despite  saline  infusion  and  all  other  available  meas- 
ures, he  failed  to  rally  from  the  operation,  dying  during  the 
same  day. 

The  cachexia  in  this  case,  which  was  mistaken  for  that  of 
cancer,  was  evidently  of  non-malignant  origin.  An  exploratory 
laparotomy  months  earlier  would  have  revealed  the  true  cause 
of  the  patient's  failing  health,  and  would  undoubtedly  have 
saved  his  life. 

Case  XIX. — S.  C.  S.,  male,  butcher,  aged  33.  Referred  by 
Dr.  W.  B.  Thompson,  of  Brooklyn,  November  28,  1909. 

Previous  History. — History  of  "stomach  trouble."  Would 
vomit  for  days  at  a  time.  Pain  very  great  after  eating.  Abso- 
lutely no  specific  history  obtainable.  Patient  consulted  several 
physicians,  with  varying  results  as  to  diagnosis.  By  some  the 
trouble  was  pronounced  ulcer  of  the  stomach,  by  others  loco- 
motor ataxia,  hyperchlorhydria,  chronic  appendicitis,  and  early 
malignancy.     Received  medical  treatment,  but  without  relief. 

Physical  Examination. — ISTo  evidence  of  a  tumor,  but  a  dis- 
tinct area  of  epigastric  resistance.  Pain  and  tenderness  upon 
palpation. 

X-ray  Examination,  by  Dr.  Lewis  Gregory  Cole,  showed  con- 
striction on  the  greater  curvature  of  the  stomach,  very  close  to 
the  pylorus.  This  constriction,  although  not  very  extensive, 
was  persistent  in  all  the  plates,  and  was  quite  suggestive  of 
carcinoma. 

Operation,  New  York  Polyclinic  Hospital,  January  14,  1910. 
Laparotomy.  Appendix  markedly  diseased,  containing  two 
stones  as  large  and  longer  than  the  phalanx  of  the  index  finger. 
Some  adhesions  around  the  appendix,  and  also  around  the  outer 
side  of  the  gall-bladder.  No  evidence  of  cancer  of  stomach, 
although  wall  congested  and  thickened. 

Subsequent  History. — Uneventful  recovery  from  operation. 
Symptoms  relieved  for  a  time,  but  soon  returned,  becoming  as 
severe  as  before  surgical  treatment.  Symptoms  continuing,  a 
Wassermann  test  was  made  early  in  1912,  with  positive  findings. 
He  was  given  "606,"  followed  by  inunctions  of  mercury,  with 
relief  of  all  symptoms.    Well  April  1,  1913. 

In  connection  with  this  case  it  may  be  of  interest  to  note 
that,  in  a  series  of  cases  examined  by  one  of  the  Fellows  of 
the  Research  Department  of  the  New  York  Skin  and  Cancer 


POSSIBLE    P:RR0RS    in    diagnosis  209 

Hospital,^  Wassermann  test  was  positive  in  only  two  out 
of  212  cases  of  cancer.  In  one  of  these  it  was  weak,  in  the 
other  strong,  and  in  both,  specific  disease  was  a  possibility.  In 
over  1,400  control  cases  of  syphilis,  the  test,  in  each  instance, 
was  positive. 

The  case  under  consideration  is  an  excellent  illustration  of 
the  need,  in  obscure  abdominal  cases,  of  resort  to  all  modern 
diagnostic  measures,  including  those  for  syphilis.  It  is  known 
that  syphilis  may  cause  various  gastric  disorders  as  well  as  con- 
striction of  the  pylorus  or  other  part  of  the  stomach.  The  re- 
sulting symptoms  may  be  easily  confounded  with  those  of  car- 
cinonaa. 

That  this  man  had  a  badly  diseased  appendix  and  needed  its 
removal  was  undoubtedly  true,  but  appendectomy  did  not  cure 
him  of  stomach  trouble.    Antisyphilitic  treatment  did. 

Type    II 

Cases  of  Cancer,  not  Recognized  as  Such,  hut  Diagnosed  arid 
Treated  as  Something  Else. — Just  as  in  the  foregoing  type  the 
various  conditions  mentioned  might  be  mistaken  for  cancer,  so 
in  this  type,  cancer  may  be  mistaken  for  the  various  conditions 
named.  Even  upon  exploratory  operation  the  cancer  may  be 
overlooked,  because  of  the  presumptive  existence  of  some  other 
condition.  Cases  of  this  type  call  for  the  most  careful  observa- 
tion of  the  entire  field  of  exploration,  in  order  that  no  focus  of 
malignancy,  however  small,  may  be  overlooked. 

Case  XX. — G.  D.,  female,  married,  aged  45. 

Previous  History. — History  of  chronic  intestinal  stasis,  with 
what  seemed  to  be  repeated  attacks  of  appendicitis.  Had  been 
ill  for  many  months  with  pain  in  right  side;  diagnosed  as 
chronic  appendicitis.     Three  weeks  before  admission  was  op- 

1  Fox,  Frederick  J. — ' '  The  Wassermann  Eeaetion  in  Cancer, ' '  Medical 
Record,  August  16,  1913,  p.  283.     See  also: 

Caan,  A. — ' '  Ueber  Koraplementablenkung  bei  Karzinom, ' '  Miinch.  med. 
Wochenschr.,  April  4,  1911,  LVIII,  p.  731. 

Newmark,  L. — ' '  The  Occurrence  of  a  Positive  Wassermann  Reaction 
in  Two  Cases  of  Non-Specific  Tumors  of  the  Central  Nervous  System," 
Jour.  Am.  Med.  Assn.,  Jan.  6,  1912,  p.  11. 

Foerster,  A. — ' '  Wassermann 's  Reaction  in  Relation  to  Cancer, ' '  Lancet, 
June  24,  1911,  p.  1695. 

Barrett,  C- — "Ueber  Komplementablenkung  bei  Menschencarcinom, " 
Zeitschr.  f.  Kreisforschung ,  Berlin,  1911,  XI,  p.  245. 

Pinkuss,  A.—' '  Weitere  Erf  ahrungen  iiber  Serologische  Diagnostik  Verlaiif 
u.  Behandlung  des  Karzinoms,"  Deut.  med.  Woch.,  1912,  XXXVIII  (2nd 
paper),  p.  119. 

Rosenberg,  M. — "Zur  Frage  der  Serologischen  Karzinomdiagnostik, " 
Deut.  med.  Woch.,  1912,  XXXVIII,  p.  1225. 


210  THE    CANCER    PROBLEM 

erated  upon  and  a  mass  confined  to  the  head  of  the  cecum  and 
appendix  was  found.     Cut  into  and  drained. 

Physical  Examination. — Cancerous  sinus  at  the  site  of  the 
scar  from  the  ''appendicitis"  operation.  This  was  discharging 
mixed-infection  pus.    Mass  in  right  iliac  fossa. 

Operation. — New  York  Skin  and  Cancer  Hospital,  Decem- 
ber 12,  1912,  exploratory  laparotomy.  The  cancerous  sinus  was 
found  surrounded  by  large  and  small  intestine,  which  had  be- 
come part  of  the  sinus  wall.  The  original  growth  was  easily 
removable,  and  there  were  no  glands  which  could  not  have  been 
removed  with  ease.  But  the  extension  by  contiguity  to  two  feet 
of  small  intestine,  cecum,  and  ascending  colon  made  it  impos- 
sible to  thoroughly  eradicate  the  disease. 

Subsequent  History. — Patient  died  a  few  days  after  opera- 
tion. 

This  case  emphasizes  very  strongly,  not  enly  the  impor- 
tance of  careful  diagnosis,  previous  to  laparotomy  operation, 
but  also  the  importance  of  the  careful  exploration  of  the  field 
involved.  It  is  an  excellent  illustration  of  the  danger  of  break- 
ing down  the  barriers  by  means  of  which  nature  endeavors  to 
protect  the  rest  of  the  organism  from  invasion  by  cancer.  When 
this  patient  was  operated  upon  for  presumptive  appendicitis 
it  is  quite  probable  that  the  diseased  tissue  might  have  been 
entirely  removed  without  danger  of  auto-infection  of  the  other 
parts.  Three  weeks  later  extension  had  taken  place  so  rapidly 
that  complete  eradication  was  impossible. 

Case  XXI. — D.  Le  R.,  female,  married,  aged  62  years.  Ad- 
mitted to  the  ISTew  York  Skin  and  Cancer  Hospital,  April  3, 
1912. 

Previous  History. — For  a  year  and  a  half  before  admission 
had  had  the  usual  symptoms  of  chronic  constipation,  gastric 
disorder,  vomiting,  with  typical  symptoms  of  "biliousness,"  and 
a  slowly  growing  mass  in  the  right  iliac  fossa.  Later,  diarrhea. 
Diagnosis  of  gall-stones,  with  fecal  retention  in  the  ascending 
colon.  Treated  medically.  Lost  12  pounds  in  weight.  Diar- 
rhea and  cachexia  had  become  quite  marked  by  the  time  I  first 
saw  the  patient. 

Physical  Examination. — Large  mass  in  right  iliac  fossa,  ex- 
tending upward  almost  to  the  liver. 

Operation,  exploratory  laparotomy,  April  26,  1913.  Cauli- 
flower-like cancer  of  caput  coli,  extending  up  to  the  ascending 
colon,  and  acting  as  a  valve,  flapping  against  the  ileocecal  open- 
ing.    Small  intestine  secondarily  involved.     Irremovable. 

Exploratory  laparotomy  at  an  earlier  stage,  when  the  diag- 
nosis of  gall-stones  was  first  made,  would  doubtless  have  ren- 


POSSIBLE    ERRORS    IN    DIAGNOSIS  211 

dered  possible  the  thorough  eradication  of  the  disease.  There 
was  over  a  year  of  delay  from  the  time  of  the  appearance  of 
the  growth  until  the  possibility  of  cancer  was  considered  and 
surgical  treatment  instituted. 

Case  XXII. — A,  H.,  female,  widow,  aged  48,  three  chil- 
dren. Admitted  to  the  New  York  Skin  and  Cancer  Hospital, 
November  27,  1908. 

Previous  History. — Seventeen  months  before  admission  pa- 
tient began  to  suffer  from  "indigestion" — a  constant  burning 
behind  the  sternum,  sometimes  relieved  by  vomiting.  Never 
vomited  blood.  Diagnosis  of  "nervous  dyspepsia"  made,  and 
symptomatic  treatment  instituted.  Vomiting  increased  in  fre- 
quency. Great  loss  of  flesh  and  strength.  Upon  admission  to 
the  hospital  had  been  unable  to  retain  any  food  for  many 
weeks. 

Physical  Examination. — Mass  in  pyloric  region  size  of  an 
orange. 

Operation,  December  4,  1908.  An  irremovable  mass,  with 
enlarged  glands  way  up  behind  the  stomach  and  liver.  Pylorus 
occluded.     Retrocolic  gastrojejunostomy  performed. 

Subsequent  History. — Patient  returned  to  the  hospital  June 
11,  1909,  complaining  of  vomiting  after  eating  sweets — the 
first  trouble  after  the  operation.  She  was  kept  in  bed  for  a  time 
on  restricted  diet.  Continued  in  good  health  until  May,  1911, 
when,  after  exposure,  she  contracted  a  severe  cough,  acute 
tuberculosis  developed,  and  the  patient  died  in  Bellevue  Hos- 
pital, August  6,  1911. 

This  case  emphasizes  the  importance  of  exploratory  lapar- 
otomy in  obscure  abdominal  conditions  which,  upon  super- 
ficial examination,  appear  to  be  "indigestion,"  "nervous  dyspep- 
sia," etc.  An  earlier  operation  would  doubtless  have  enabled 
the  patient  to  live  out  her  allotted  span.  As  it  was,  by  the  pal- 
liative measure  employed,  she  lived  two  and  a  half  years  in  fair 
health  and  comfort,  the  immediate  cause  of  death  being  an  en- 
tirely different  disease. 

Type    III 

Cases  of  Small  Cancer ^  diagnosed  as  Cancer,  hut  having  far 
more  of  something  else  present,  the  latter  condition  or  condi- 
tions being  mistaken  for  malignancy,  or  being  considered  too 
serious,  in  conjunction  with  the  cancer,  to  warrant  operative  in- 
terference. Neglect  in  such  cases  allows  an  early  and  remov- 
able cancer  to  become  advanced  and  perhaps  irremovable ; 
whereas,  by  exploration,  it  could  be  easily  determined  that  the 


212  THE    CANCER    PROBLEM 

entire  condition,  including  the  small  cancer,  might  be  corrected 
bv  surgical  procedure.  Oases  of  this  class  are  not  so  common 
as  those  of  the  first  and  second  type,  but  undoubtedly  many 
more  would  be  found  if  exploratory  laparotomy  were  more  com- 
monly and  more  carefully  employed. 

Case  XXIII. ^ — J.  L.,  female,  married,  aged  46  years.  Ad- 
mitted to  the  New  York  Skin  and  Cancer  Hospital,  April  29, 
1907,  referred  by  Dr.  Henry  McCastline,  New  York  City. 

Previous  History. — Headache,  pain  in  the  back,  dragging 
sensation  on  walking  or  standing,  occasional  vomiting.  En- 
largement of  abdomen.  Gradual  loss  of  flesh  and  strength. 
Diagnosed  as  gall-stones,  with  an  ovarian  cyst  probably  under- 
going cancerous  degeneration. 

Physical  Examination. — Enormous  enlargement  of  abdomen. 

Operation,  April  30,  1907.  Laparotomy.  Removal  of  right 
ovarian  cyst,  which  weighed  twenty-six  and  one-half  pounds. 
Left  ovary  contained  small  cysts,  and  was  the  seat  of  a  tumor 
the  size  of  a  hickory  nut,  which  suggested  benign  carcinoma, 
and  proved  such  upon  microscopic  examination.  The  left  ovary 
and  tube  were  excised.  The  appendix,  which  was  bound  down 
by  adhesions,  was  removed.  The  gall-bladder  was  found  much 
distended  and  containing  gall-stones.  The  gall-bladder  was 
stitched  into  a  vertical  wound  just  below  the  edge  of  the  ninth 
costal  cartilage.  Two  days  later  it  was  opened  and  fifty  gall- 
stones removed.  Free  drainage  was  allowed.  No  cancer  found 
elsewhere  than  in  the  left  ovary. 

Subsequent  History. — Uneventful  recovery.  Perfectly  well, 
April  1,  1913. 

Believing  that  cancerous  degeneration  of  the  ovarian  cyst, 
and  perhaps  of  the  gall-bladder  and  ducts,  existed,  opera- 
tion was  not  undertaken  by  the  surgeon  first  consulted.  Ex- 
ploratory laparotomy,  however,  revealed  the  fact  that  the  very 
small  cancer  of  the  other  ovary,  and  also  the  gall-stones,  which 
were  the  real  cause  of  most  of  the  patient's  discomfort,  were 
amenable  to  surgical  treatment.  Without  exploratory  laparot- 
omy these  facts  could  not  have  been  ascertained.  Without  the 
knowledge  of  the  real  condition,  gained  by  such  procedure,  the 
patient  would  have  been  left  to  her  fate. 

^Reported  (Bainbridge),  with  illustrations,  in  "Irremovable  Cancer," 
N.  Y.  Med.  Jour.,  October  3,  1908,  p.  625,  being  an  abstract  of  the  Fourth 
Annual  Clinical  Lecture  on  Cancer,  delivered  at  the  New  York  Skin  and 
Cancer  Hospital,  April  22,   1908. 


POSSIBLE    ERRORS    IN    DIAGNOSIS  213 

Type    IV 

Cases  of  Advanced  Cancer,  diagnosed  as  such,  hut  made 
seemingly  hopeless  hy  an  added  condition  which,  in  itself,  is 
not  of  serious  moment  so  far  as  prognosis  is  concerned.  Cor- 
rection of  the  complications  in  this  type  of  cases  is  a  matter  of 
surgical  technic,  as  is  likewise  the  removal  of  the  cancer. 

Case  XXIV. — G.  H.,  married,  female,  aged  54.  Referred 
by  Dr.  lienrj  Hughes,  Long  Branch,  N.  J.,  November  10,  1909. 

Previous  History. — Eectal  trouble,  with  chronic  constipation, 
for  three  years.  In  May,  1909,  laparotomy  was  performed  by 
another  surgeon,  with  the  purpose  of  removing  a  cancer  of  the 
lower  bowel,  but  so  many  adhesions  were  found  that  nothing 
was  done,  the  case  being  considered  one  of  inoperable  cancer, 
with  general  visceral  extension. 

Physical  Examination. — Chronic  intestinal  stasis.  Marked 
cachexia.  Great  loss  of  flesh  and  strength.  Lower  pelvic  colon 
almost  totally  obstructed  by  advanced  cancer  of  rectum. 

Operation,  November  22,  1909.  With  the  hope  that  the  first 
operator  had  been  mistaken  in  the  extent  of  the  disease,  and 
believing  that  if  this  were  not  the  case  a  colostomy  would  give 
relief,  exploratory  laparotomy  was  performed.  Extensive  ad- 
hesions were  found,  but  they  were  clearly  from  an  old  peritoni- 
tis following  childbirth  years  before,  and  from  the  operation  in 
May.  These  were  separated.  Diseased  left  ovary  and  tube 
found,  salpingo-oophorectomy  performed.  By  the  combined 
operation,  using  the  vaginal  outlet,  21/0  f^st  of  intestine,  with 
mesorectum  and  mesosigmoid,  removed.  Cut  end  of  rectum 
was  brought  into  the  pelvis.  Sphincter,  with  last  two  inches  of 
rectum,  saved. 

Subsequent  History. — Uninterrupted  recovery.  Has  at  pres- 
ent some  abdominal  adhesions,  necessitating  the  taking  of  ca- 
thartics, but  has  perfect  control  of  bowel.  Has  gained  33 
pounds  in  weight,  and  was  perfectly  well,  Jan.  1,  1914. 

This  case  emphasizes  the  importance  of  diiferentiating  be- 
tween malignant  and  non-malignant  adhesions,  between  an 
inflammatory  condition  of  tubes  and  ovaries  (which  pathologi- 
cal examination  proved  to  be  the  case  here,  with  no  malignancy 
present)  and  cancer.  Valuable  time  was  lost  by  the  failure  to 
recognize  these  differences,  and  the  patient  was  nearly  sacri- 
ficed. 

Type    V 

Cases  in  which  the  Error  in  Diagnosis  Concerns  the  Stage  of 
Extent  of  the   Cancer.     Seemingly  inoperable  and  incurable 


214  THE    CANCER    PROBLEM 

cases  may  be  operable  and  curable  by  resort  to  special  methods, 
an  example  of  which  is  the  operation  of  arterial  ligation,  with 
"hTuphatic  block,"  described  in  Section  XI,  Chapter  II. 

Case  XXV. — C.  U.  S.,  female,  widow,  aged  44.  Referred 
by  Dr.  Eliza  M.  Mosher,  of  Brooklyn,  November  19,  1910. 

Previous  History. — Leucorrhea,  sometimes  tinged  with 
blood,  for  several  years,  especially  since  laceration  cf  cervix  at 
birth  of  fourth  child.  Diagnosis  of  irremovable  cancer  of 
uterus  made  by  two  surgeons. 

Physical  Examination. — Evidence  of  advanced  cancer  of 
uterus,  with  apparent  involvement  of  broad  ligaments  and  pelvic 
glands. 

Operation,  Alston's  Private  Sanitarium,  November  15,  1910. 
Arterial  ligation  of  pelvic  vessels,  with  "lymphatic  block" ; 
panhysterectomy,  with  vaginectomy  (Wertheim). 

Subsequent  History. — Uneventful  recovery,  strong  and  per- 
fectly well,  January  1,  1914. 

Had  the  opinion  been  followed  in  this  case  which  was  ex- 
pressed before  the  Medical  Society  of  the  State  of  New  York 
last  year  by  one  of  its  distinguished  members,  to  the  effect 
that  when  the  glands  are  palpable  it  is  too  late  for  even  a 
Wertheim  operation,  this  patient  would  have  been  left  to  her 
fate.  As  it  was,  by  tying  off  blood  vessels  and  removing  the 
glands  along  the  ureters,  from  the  obturator  foramen  to  the 
receptaculum  chyli,  it  became  possible  to  do  what  seemed  im- 
possible before,  and  a  complete  removal  of  all  disease  was 
effected. 

Type    VI 

Cases  of  Cancer  in  which  the  Error  in  Diagnosis  Concerns 
the  Type  of  Malignant  Growth.  One  type,  of  a  given  stage  of 
development,  or  of  a  given  extent,  may  be  incurable;  another, 
of  a  corresponding  stage  or  extent,  may  be  curable.  It  is  fair 
to  assume  that  such  cases  are  not  of  very  common  occurrence, 
but  they  are  none  the  less  important,  and  should  always  be 
borne  in  mind. 

Case  XXVI. — R.  V.,^  female,  married,  aged  29  years.  First 
consulted  me  May  19,  1907. 

Previous  History. — Patient  had  had  an  exploratory  laparot- 
omy in  another  city,  the  clinical  diagnosis  of  round-celled  sar- 
coma being  made  at  that  time,  the  growth  being  pronounced 
irremovable. 

^ Bainbridge. —  (1)  "Irremovable  Cancer,"  N.  Y.  Med.  Jour.,  Oct.  3, 
1908,  p.  625. 

( 2 )  "  Oxygen  in  Medicine  and  Surgery — A  Contribution,  with  Beport 
of  Cases,"  N.  Y.  State  Jour,  of  Medicine,  June,  1908,  p.  281. 


POSSIBLE    ERRORS    IN    DIAGNOSIS  215 

Physical  examination  and  the  history  of  the  case  did  not 
warrant,  in  my  opinion,  the  diagnosis  of  irremovable  sarcoma, 
and  another  exploratory  laparotomy  was  advised. 

Operation,  June  12,  1907,  at  the  New  York  Skin  and  Cancer 
Hospital.  Papillomatous  degeneration  of  the  uterus,  tubes, 
and  ovaries  found,  extending  to  the  intestines  and  well  up  on  to 
the  liver.  A  detached  portion  was  removed  for  microscopical 
examination,  the  report  being  "malignant  papilloma."  Ten 
days  later  panhysterectomy  was  performed,  and  a  large  amount 
of  fluid  evacuated.  A  large  papillomatous  mass  in  the  pelvis 
was  also  removed. 

Subsequent  History. — Since  the  above  operations  patient  haa 
undergone  10  laparotomies  by  the  writer,  making  12  in  all,  in 
addition  to  one  by  the  other  surgeon,  and  67  tappings  for  the 
evacuation  of  serosanguineous  fluid.  About  every  six  months 
the  abdomen  is  opened,  more  of  the  papillomatous  material 
removed,  and  oxygen  usually  introduced  by  the  method  de- 
scribed elsewhere.-^  The  disease  is  much  less  extensive  than  it 
was  nearly  7  years  ago.  The  fluid  still  collects  in  the  abdomen, 
necessitating  tappings.  The  patient  remains  in  the  hospital 
two  or  three  weeks  after  each  laparotomy,  and  two  or  three 
hours  after  each  paracentesis  abdominalis.  She  has  no  ca- 
chexia, her  bowels  move  regularly,  her  color  is  good,  she  weighs 
forty  pounds  more  than  she  did  7  years  ago,  is  able  to  do  her 
housework,  and,  except  for  the  discomfort  experienced  when 
the  abdomen  fills  with  fluid,  feels  perfectly  well. 

This  case  emphasizes  the  importance  of  differentiating  the 
type  of  malignant  neoplasms.  Had  this  patient  been  the  vic- 
tim of  sarcoma,  or  adenocarcinoma  of  a  corresponding  degree 
of  extension  when  I  first  saw  her,  she  would  have  been  dead 
years  ago.  Had  she  been  left  without  surgical  intervention  the 
malignant  papilloma  would  have  proved  fatal  long  ago. 

Moynihan,  Rodman,  Mayo,  Kemp,  Syms,  Paterson,  and 
many  others  have  called  attention  to  the  necessity  of  early  ex- 
ploratory laparotomy.  The  statistics  of  many  hospitals  are 
illustrative  of  the  frequency  of  mistaken  diagnosis  in  abdominal 
conditions.  The  proportion  of  cases  of  abdominal  cancer  in 
which  this  disease  is  first  recognized  on  the  operating  table  or 
at  autopsy,  is  variously  estimated,  according  to  the  part  in- 
volved, at  from  twenty  to  sixty  per  cent. 

It  is  not  to  be  inferred  that  exploratory  laparotomy  is  advo- 
cated indiscriminately,  or  without  a  careful  examination  by  all 

^  Bainbridge. — Loc.  cit.   (2). 

See  also:  "The  Intra- Abdominal  Administration  of  Oxygen,"  Annals^ 
of  Surgery,  March,  1909,  p.  305. 


216  THE    CANCER    PROBLEM 

the  diagnostic  methods  at  our  command,  extending  over  a  rea- 
sonable length  of  time.  It  is  undeniable,  however,  that  test- 
meals,  gastroscopic  examinations,  X-ray  exposures,  and  various 
other  non-surgical  diagnostic  measures,  with  periods  of  trial 
treatment,  may  be  the  means,  by  virtue  of  the  delay  entailed,  of 
plunging  the  patient  into  the  slough  of  despond — the  irremov- 
able stage  of  cancer — when  only  palliative  measures  may  be 
employed. 

PELVIC  ORGANS 

Case  XXVII. — Cancer  of  the  Breast  and  Uterine  Fibroids. 
— A.  F.,  female,  aged  48,  private  patient,  referred  to  me  for 
operation  for  cancer  of  the  uterus.  Right  breast  had  been 
amputated  four  months  previously  by  another  surgeon.  Shortly 
after  recovery  from  this  operation  the  patient  had  two  uterine 
hemorrhages,  and  for  the  first  time  the  physician  made  a  vaginal 
examination.  He  found  a  large  tumor  in  the  uterus,  and  pro- 
nounced it  a  case  of  advanced  cancer.  He  expressed  to  the 
husband  his  doubt  as  to  the  possibility  of  anything  being  done, 
but  advised  trying.  I  saw  the  patient  in  consultation  and  made 
a  thorough  examination.  The  uterus  was  retroverted,  there  was 
some  fungous  endometritis,  and  a  fibroid  the  size  of  a  large 
orange  was  found  in  the  fundus.  In  the  right  side,  where  the 
drainage  had  been  inserted  at  the  time  of  the  breast  amputation, 
were  a  few  small  nodules,  extending  into  the  axilla.  In  the  left 
breast  was  an  actively  growing  malignant  tumor,  with  lower 
axillary  glands  enlarged.  The  patient  was  sent  away  for  a  few 
days'  rest  in  the  country,  and  upon  her  return  we  removed  the 
left  breast,  clearing  the  axilla,  and  curetted  the  uterus.  Her 
condition  has  been  much  improved  since  the  operation.  A  few 
nodules  have  appeared  in  the  skin  over  the  sternum,  carcinoma 
en  cuirasse,  which  seem  to  be  diminishing  under  treatment  with 
X-ray.  Microscopic  examinations  of  scrapings  from  uterus 
showed  simple  endometritis. 

Case  XXVIII.  Uterine  Polypus. — Single  woman,  26  years 
of  age,  had  had  bleeding  from  uterus  for  some  months.  Pro- 
fuse menstruation  for  some  years.  Diagnosis  of  uterine  cancer 
had  been  made.  Careful  examination  revealed  no  malignancy, 
but  a  polypus,  which  was  snipped  off,  with  resulting  cessation 
of  bleeding.     Perfectly  well  since. 

Case  XXIX.  Cancer  of  the  Uterus,  Irremovable ;  Large  Ul- 
cerating Mass. — W.  S.,  female,  married,  aged  about  50.  Pa- 
tient had  always  been  apparently  perfectly  well  until  three 
years  before  operation,  at  which  time  she  began  to  have  some 
irregularity  in  menstruation  and  certain  nervous  symptoms,  all 


POSSIBLE    ERRORS    IN    DIAGNOSIS  217 

considered  as  indications  of  the  establishment  of  the  meno- 
pause. There  was  gradual  loss  of  weight  and  strength.  Sud- 
denly, and  without  special  warning,  an  alarming  hemorrhage 
occurred,  in  May,  1909.  Dr.  Ellis  Hedges,  the  family  physi- 
cian, made  an  examination,  finding  a  large,  ulcerating  mass  in 
the  pelvis.  lie  tamponed  the  vagina,  and  demanded  consulta- 
tion. Eight  distinguished  gynecologists  or  surgeons  were  con- 
sulted. Curettage  was  proposed  as  the  only  possible  operative 
procedure.  This  was  attempted,  under  ether,  by  Dr.  Hedges, 
but  the  extent  of  the  disease  and  the  friability  of  the  tissues 
made  thorough  curettage  impossible.  Acetone  was  applied  lo- 
cally after  this.  The  author  was  then  called  in  consultation, 
and  ligation  of  the  arteries  supplying  the  diseased  parts  was 
proposed  by  him.  Accordingly,  on  May  8,  1909,  at  the  home  of 
the  patient,  laparotomy  was  performed.  The  cancer  was  found 
to  be  irremovable.  The  left  ureter  was  obstructed  by  cicatricial 
contraction  of  the  diseased  tissue  surrounding  it.  It  was  as 
large  as  the  finger,  and  stood  out  like  a  whipcord.  It  was 
stripped  up  and  freed  from  this  constriction.  Both  ovarians, 
both  internal  iliacs,  and  the  sacra  media  were  ligated.  Glands 
were  removed  to  block  lymphatic  channels  as  much  as  pos- 
sible. At  the  request  of  the  family,  radiogelatin  was  employed, 
two  drachms  being  injected  into  the  tissues  in  the  neighborhood 
of  the  cancer  in  the  body  of  the  uterus.  There  was  considerable 
collapse  at  the  time  of  the  operation,  but  the  patient  made  an 
uneventful  recovery. 

The  hemorrhage  was  absolutely  controlled ;  the  bladder  symp- 
toms which  had  been  present  before  disappeared;  the  pain, 
weight,  and  tenderness  in  the  obstructed  left  kidney  were  re- 
lieved by  freeing  the  ureter;  the  discharge  was  lessened,  and 
the  general  condition  was  improved.  The  patient  gained  six- 
teen pounds  in  weight,  was  able  to  preside  at  her  own  table,  to 
take  automobile  rides,  to  go  to  the  seashore,  and  later  to  the 
mountains. 

At  the  time  of  operation  she  was  given  a  general  anesthetic, 
ostensibly  for  the  purpose  of  making  an  examination  and  apply- 
ing acetone,  and  so  never  knew  that  she  had  undergone  a  seri- 
ous operation  until  long  afterward,  when  she  discovered  the 
scar  at  the  site  of  the  abdominal  wound.  She  never  knew  that 
she  had  cancer.  She  returned  home  in  September,  1909,  and 
after  an  illness  of  two  weeks  she  died,  probably  from  the  shut- 
ting off  of  the  kidneys  by  extension  of  the  cancerous  process. 
Death  occurred  October  2,  1909. 

If  the  earlier  symptoms  had  not  been  attributed  merely  to 
the  menopause,  and  if  the  patient  had  allowed  an  examination, 


218  THE    CANCER    PROBLEM 

a  correct  diagnosis  might  have  been  made  in  the  beginning  and 
she  might  have  been  cured.  Cases  of  this  kind,  which  are  all 
too  numerous,  should  emphasize  the  importance  of  careful  ex- 
amination, and  of  periodical  examination,  in  the  presence  of 
menstrual  irregularities. 

Case  XXX. ^  Hodghms  Disease. — H,,  female,  married, 
aged  43  years.  Admitted  to  my  service  at  the  New  York  Skin 
and  Cancer  Hospital,  Alarch  17,  1911.  Present  illness  began  in 
Xovember,  1910,  with  enlargement  of  glands  of  both  axilhe. 
Two  weeks  later  glands  of  right  groin  enlarged,  then  glands  of 
neck,  and  finally  there  was  general  enlargement  of  the  external 
glands  to  the  size  of  a  pea  or  greater.  Upon  examination  the 
neck  and  breasts  were  found  to  be  greatly  swollen,  and  the  skin 
tense  over  this  area.  Vaginal  examination  showed  an  enlarged 
uterus.  The  clinical  diagnosis  of  sarcoma  of  the  uterus,  with 
metastasis  in  the  l^nnph  nodes,  was  made.  The  patient  was 
under  observation  for  three  months.  Inguinal  nodes  excised 
for  examination  showed  necrosis.  Axillary  nodes  excised  a 
month  later  showed  typical  tubercle  tissue  with  giant  cells. 
Later  examination  revealed  tubercle  bacilli.  Thickening  and 
infection  of  the  skin  resulted  from  the  patient's  scratching. 
Sections  of  this  thickened  skin  showed  inflammatory  changes, 
but  nothing  on  which  to  base  a  diagnosis  of  new  growth  or  of 
Hodgkin's  disease.  The  patient  died,  June  25,  1911,  appar- 
ently from  exhaustion. 

The  uterus,  upon  post-mortem  examination,  was  found  to 
measure  12  cm.  in  length  and  9x6  cm.  at  fundus.  Surface 
nodular.  Entire  wall  infiltrated  with  growth  of  dense  fibrous 
tissue,  which  had  caused  apparent  destruction  of  all  the  muscu- 
laris.  Tubes  presented  similar  nodular  thickening  at  uterine 
end.  Ovaries  normal  size ;  fibrous.  Microscopical  examination 
of  sections  of  different  parts  of  the  uterus  showed  growth  of 
endothelial  cells,  small  round  cells,  with  scattered  giant  cells. 
Portions  were  densely  fibrous  in  character.  The  mucosa  was 
almost  entirely  replaced  by  the  growth,  only  a  few  scattered 
glands  appearing  in  sections  from  the  body  and  cervix.  The 
nodules  in  the  tubes  and  in  one  ovary  showed  similar  changes. 
The  appearance  characteristic  of  Hodgkin's  disease  was  found 
in  the  mesenteric,  iliac,  and  bronchial  lymph  nodes,  in  the 
breast,  and  beneath  the  skin  of  the  neck.  The  spleen  gave  evi- 
dence of  recent  involvement. 

The  diagnosis  was  made  of  Hodgkin's  disease  involving  the 

1  .Tessup,  D.  S.  D. — "Hodgkin's  Disease  Involving  the  Uterus,"  Am. 
Jour,  of  Obstet.  and  Dis.  of  Women  and  Children,  Vol.  LXVI,  No.  3,  1912, 
N.  S.  12,  p.  3. 


POSSIBLE    ERRORS    IN    DIAGNOSIS  219 

uterus,  tubes,  and  ovary.  From  the  standpoint  of  clinical  diag- 
nosis the  case  is  of  interest,  the  enlargement  of  the  -Literus  sug- 
gesting a  new  growth  of  an  advanced,  inoperable  character,  with 
metastases  in  most  of  the  superficial  lymph  glands. 

This  was  a  rare  condition.  It  served  to  emphasize  the  im- 
portance, in  diagnosis,  of  considering  as  far  as  feasible  all  pos- 
sibilities. The  rare  condition  may  be  present  in  the  case  in 
hand. 

SUMMARY 

The  fact  that  about  8  to  9  per  cent,  of  the  patients  operated 
on  for  cancer  or  sent  to  the  mortuary  as  dead  of  it  were  not 
sufferers  from  the  disease  has  two  very  important  consequences 
for  the  general  public.  The  proportion  is  probably  not  less 
among  the  large  number  of  patients  who  seek  hospital  advice, 
but  who  are  either  unwilling  to  undergo  operation  or  are  too 
late  in  seeking  relief  by  this  means.  Many  of  these  patients 
drift  from  one  quack  to  another,  or  seek  the  aid  of  members  of 
the  medical  profession  who  claim  to  cure  cancer  without  the 
knife.  This  circumstance  accounts  very  largely  for  the  claims 
often  made  that  a  patient  has  been  cured,  after  a  diagnosis  of 
cancer  has  been  made  by  a  distinguished  surgeon,  or  a  case  has 
been  pronounced  inoperable  by  some  hospital  authority.  On 
the  other  hand,  the  public  should  appreciate  that  not  every 
lump  or  ulcer  is  cancerous,  and  that,  owing  to  the  difficulties 
of  diagnosis,  unnecessary  fears  ought  to  be  allayed  by  seeking 
at  once  the  advice  of  honorable  members  of  the  medical  pro- 
fession able  to  distinguish  inflammatory  swellings,  especially 
syphilitic  or  tuberculous,  from  benig-n  tumors,  cysts,  mere  hy- 
pertrophic nodules,  and  malignant  new  growths.  Morbid  fears 
of  cancer  are  often  entertained  by  those  who  have  had  relatives 
die  of  it  or  have  been  brought  in  contact  with  friends  so  af- 
flicted. It  behooves  all  such  not  to  nurse  their  anxieties,  but  to 
seek  immediate  advice  lest  the  truth  be  learned  too  late  for 
surgical  aid,  or  dread  of  cancer  needlessly  darken  the  days  of  a 
perfectly  healthy  person. 


SECTION    VIII 

PROPHYLAXIS 

The  prevention  of  cancer  does  not  depend,  as  in  the  case  of 
diseases  known  to  be  of  specific  origin,  npon  the  destruction  of 
the  established  causative  organism  or  its  resistant  forms,  or 
npon  the  removal  of  the  definite  and  recognized  source  of  con- 
tamination ;  it  depends,  rather,  upon  the  elimination  of  one  or 
more  of  a  large  number  and  variety  of  possible  predisposing 
factors  and  precancerous  conditions. 

The  predisposing  elements  which  have  been  suggested  and 
which  are  accepted  by  some  as  having  greater  or  less  etiological 
significance,  are:  race,  sex,  heredity,  general  nutrition,  local 
nutrition,  chronic  irritation,  repeated  acute  trauma,  chronic 
inflammation,  cicatricial  tissue,  benign  tumors,  and  local  mani- 
festations of  certain  diseases,  such  as  tuberculosis,  syphilis,  and 
diabetes,  especially  syphilis  in  the  case  of  the  tongue. 

It  has  been  said  ^  that  there  is  "scarcely  an  instance  of  a  com- 
plete account  of  a  case  of  visible  cancer  that  does  not  give  a  clear 
precancerous  history — a  history  of  chronic  irritation,  ulcer, 
scar,  hyperplasia,  innocent  tumor,  or  a  combination  of  these 
factors."  Experience  and  observation  frequently  bear  out  this 
statement. 

Various  other  predisposing  factors,  such  as  climate,  soil,  oc- 
cupation, and  habits  of  life,  are  considered  by  some  students  of 
the  cancer  problem  as  bearing  some  relationship  to  cancer  inci- 
dence. With  the  probable  exception  of  alcohol,  their  signi- 
ficance, however,  is  not  sufficiently  well  recognized  to  warrant 
any  statements  concerning  the  possibility  of  preventing  the 
disease  by  the  correction  of  these  conditions. 

Certain  of  the  supposed  predisposing  influences,  notably  race, 
sex,  and  heredity,  are  beyond  the  control  of  the  individual 
subject  or  of  the  physician  and  surgeon.  Those  which  are  sub- 
ject to  control  or  elimination  may  be  grouped,  for  purposes  of 
convenience,  under  the  following  heads : 

'  Crile,  George  W. — "The  Cancer  Problem,"  Jour.  Am.  Med.  Assn., 
June  6,  1908,  p.  1883. 

220 


PROPHYLAXIS  221 

(1)  Environment  (diet,  hygiene,  occupation). 

(2)  Precancerous  conditions  (benign  tumors). 

(3)  Local  manifestations  of  other  diseases,  especially 
syphilis. 

(4)  Sources  of  chronic  inflammation  and  irritation. 

ENVIRONMENT 
(Diet,   Hygiene,   Occupation,   Etc.) 

The  influence  of  those  factors  which  constitute  the  physical 
environment  of  an  individual — diet,  hygiene,  habits  of  life, 
occupation,  etc. — has  been  discussed  briefly  under  the  head  of 
Geographical  and  Ethnological  Distribution  (Section  II,  Chap- 
ter 3)  ;  under  Statistical  Considerations  (Section  III)  ;  and 
under  Predisposing  Causes  (Section  IV,  Chapter  2). 

With  the  possible  exception  of  occupation  (workers  in  tar, 
soot,  petroleum,  and  anilin),  none  of  the  elements  of  environ- 
ment exert  more  than  an  indirect  influence  upon  the  incidence 
of  cancer. 

Any  such  effect  may  be  said  to  resolve  itself  into  the  impor- 
tant factor — irritation.  Thus  a  dietary  regime  which  gives 
rise  to  persistent  stomatitis,  indigestion,  and  constipation  may 
be  followed  by  ulceration  of  the  tongue  or  buccal  mucous  mem- 
branes, or  by  gastric  or  intestinal  ulcer.  Inflammation  of  the 
cervix  uteri  may  arise  from  impacted  feces  in  chronic  consti- 
pation; and  other  chronic  or  oft-repeated  irritations,  for  ex- 
ample, the  frequent  pricking  of  the  finger  in  needlewomen,  may 
furnish  fruitful  soil  for  the  development  of  malignant  disease. 
In  the  case  of  the  intestinal  canal  the  institution  of  a  regime 
which  favors  proper  assimilation  and  elimination  helps  to  re- 
move this  element  of  danger,  however  remote  it  may  appear 
to  be. 

With  reference  to  intestinal  cancer  it  is  not  to  be  inferred 
that  the  author  subscribes  to  the  views  held  by  dietary  faddists 
concerning  the  etiologic  significance  of  given  articles  of  diet. 
There  is  no  proof  of  the  influence  of  meat,  of  uncooked  vegeta- 
bles (as  the  supposed  carriers  of  parasites  which  cause  cancer), 
or  of  any  other  article  of  diet.  The  dietary  regime  is,  in  our 
opinion,  of  importance  only  in  the  maintenance  of  general 
health,  and  in  the  prevention  of  certain  conditions  associated 
with  the  predisposing  elements  in  cancer  production — chronic 
inflammation  and  irritation  of  the  intestinal  canal  itself  and 
adjacent  organs. 

The  same  may  be  said  of  general  and  personal  hygienic  regu- 
lations, as  they  pertain  to  ventilation,  exercise,  posture,  wearing 


222  THE    CANCER    PROBLExM 

apparel,  and  the  various  matters  which  concern  the  mainte- 
nance of  physical  equilibrium. 

PRECANCEROUS    CONDITIONS 

It  is  more  than  twenty  years  since  Keen  ^  first  declared  that 
pigmented  moles  may,  under  certain  circumstances,  develop 
into  cancer.  This  contention  has  been  abundantly  confirmed 
by  many  surgeons  since  that  time,  and  pigmented  moles  form 
only  one  of  a  long  list  of  so-called  benign  conditions  which  come 
within  the  category  of  the  precancerous  stage  of  malignant 
neoplasms. 

The  term  "precancerous"  may  be  challenged  because  of  the 
risk  implied  by  waiting  for  cancer  to  develop,  but  the  fact  holds 
that,  so  far  as  we  know  to-day,  certain  local  tissue  manifesta- 
tions which  may  continue  a  benign  course  in  the  life  history  of 
one  individual  may  merge  into  a  malignant  course  in  another. 

Among  the  so-called  precancerous,  or  predisposing,  condi- 
tions, the  correction  of  which  is  a  preventive  measure  so  far  as 
cancer  is  concerned,  may  be  mentioned : 

(1)  Elevated  angioma. 

(2)  Adenoma. 

(3)  Papilloma. 

(4)  Myoma. 

(5)  Adenoma. 

(6)  Xeroderma  pigmentosum.^ 

(7)  X-ray  and  other  dermatites. 

(8)  Lymphangioma  tuberosum  multiplex. 

(9)  So-called  benign  cystic  epithelioma. 

(10)  Rodent  ulcer  (really  epithelioma  of  mild  malig- 
nancy). 

(11)  Pigmented  moles. 

(12)  Acanthosis  nigricans. 

If,  as  is  now  widely  conceded,  various  benign  conditions  (by 
benign,  meaning  non-malignant  or  non-cancerous)  may  become 
cancerous,  the  responsibility  for  the  prevention  of  some  forms 
of  cancer  is  in  a  large  measure  to  be  placed  upon  the  general 
practitioner,  the  dermatologist,  the  gynecologist,  or  the  spe- 
cialist in  whatever  field,  who  is  usually  consulted  for  some  pur- 
pose before  the  surgeon  is  called  upon  to  operate  for  cancer. 

It  would  be  unwise  to  expect  a  practitioner  of  medicine  in  a 

^  Keen,  W.  W. — * '  The  Danger  of  Allowing  Warts  and  Moles  to  Eemain 
Lest  They  Become  Malignant,"  Jour.  Am.  Med.  Assn.,  1904,  XLIII,  p.  96. 

^  Councilman,  W.  T.,  and  Magrath,  G.  B. — ' '  The  Lesions  of  the  Skin 
and  the  Tumor  Formations  in  Xeroderma  Pigmentosum, ' '  Fifth  Report 
of  the  Cancer  Commission  of  Harvard  University,  1909,  p.  5. 


PROPHYLAXIS  223 

general  or  special  field  to  give  every  patient  a  thorough  physical 
examination  for  possible  conditions  which  might  lead  to  the 
initiation  of  malignancy.  Patients  would  not  submit  to  this, 
nor  would  the  physician  be  willing,  perhaps,  to  make  the  sug- 
gestion. Until,  therefore,  the  campaign  of  education  has  suffi- 
ciently impressed  the  feasibility  of  such  a  suggestion,  the  most 
that  can  be  expected  is  that  in  the  course  of  examination  and 
treatment  for  any  given  disease,  the  physician  be  watchful  with 
reference  to  conditions  which  may  be  the  precursors  of  cancer, 
advising  the  patient  what  to  do  in  the  circumstances  peculiar 
to  the  individual. 

In  the  light  of  actual  experience,  gained  from  the  study  of 
hundreds  of  cases,  the  author  has  formed  the  opinion  that  a 
large  proportion  of  severe  and  often  fatal  malignant  neoplasms 
may  be  traced  to  apparently  insignificant  and  harmless  warts, 
moles,  nevi,  and  scars,  which  have  been  subjected  to  irritation 
of  one  kind  or  another,  and  which  in  earlier  stages  would  have 
been  easily  and  completely  removable  by  surgical  means. 

Bloodgood,^  from  a  series  of  statistical  studies,  reports  that 
among  820  pathologically  fully  developed  cancers  of  the  skin 
and  visible  mucous  membranes,  he  "was  unable  to  find,  in  a 
well-taken  history,  the  absence  of  a  previous  defect  which  might 
be  looked  on  as  a  benign  precancerous  lesion."  Among  997 
epithelial  tumors  of  the  skin  and  visible  mucous  membranes, 
173  were  histologically  benign.  Of  this  group  there  was  not 
in  a  single  case  a  failure  to  cure. 

In  a  group  of  cases  of  tumors  arising  in  the  derma,  the  sub- 
cutaneous tissues,  the  fascia,  the  sheaths  of  tendons  and  nerves, 
and  the  intermuscular  connective  tissue,  Bloodgood  ^  cites  406 
distinctly  benign  cases  and  132  sarcomas.  In  48  of  the  sar- 
comas of  the  skin  the  malignant  tumors  developed  in  a  nevus  8 
times,  in  a  scar  20  times,  in  a  fibroma  9  times.  In  only  11 
cases,  therefore,  could  incrimination  of  the  benign  lesion  be  ex- 
cluded. 

The  same  author  ^  reports  769  cases  of  malignant  tirmors  of 
the  breast,  and  542  benign  lesions.  He  calls  attention  to  the 
fact  that  all  the  patients  suffering  from  malignant  lesions  were 
25  years  of  age,  or  older,  at  the  onset  of  the  disease ;  whereas,  of 
the  542  patients  with  benign  lesions,  about  130  were  under  25. 
"Therefore,"  he  argues,   "if  a  complete  operation  for  cancer 

1  Bloodgood,  Joseph  Colt. — "Control  of  Cancer,"  Jour.  Am.  Med.  Assn., 
Vol.  LXI,  No.  26,  December  27,  1913,  p.  2283. 

2  Bloodgood,  Joseph  Colt. — ' '  Diagnosis  and  Treatment  of  Border-line 
Pathological  Lesions,"  Surg.  Gyn.  and  Obstet.,  Vol.  XVIII,  No.  1,  Jan- 
uary, 1914,  p.  19. 

*  Bloodgood. — Op.  cit.,  p.  22. 


224  THE    CANCER    PROBLEM 

had  been  performed  for  every  lump  in  a  woman  over  25,  about 
50  per  cent,  would  have  been  unnecessarily  mutilated." 

It  is  not  to  be  inferred  from  what  has  been  said  that  every 
tiny  wart  or  mole,  or  other  skin  blemish,  and  every  lump  and 
bump  on  any  part  of  the  body,  is  to  be  ruthlessly  removed. 
Many  of  the  conditions  which  come  under  the  category  of  pre- 
cancerous lesions,  when  not  subjected  to  repeated  acute  trau- 
matism or  to  chronic  irritation,  give  no  trouble  in  healthy  per- 
sons whose  lives  are  regulated  on  a  well-ordered  plane.  In 
many  instances,  however,  in  a  favorable  host,  and  under  favor- 
able conditions,  as  when  subjected  to  constant  irritation  or  to 
repeated  injury,  these  otherwise  harmless  lesions  become  defi- 
nite sources  of  danger,  and  in  such  cases  removal  is  obligatory. 

LOCAL    MANIFESTATIONS    OF    OTHER    DISEASES 

Certain  pathological  states,  notably,  tuberculosis  (lupus), 
syphilis,  leukoplakia  (psoriasis  ling-use),  psoriasis  (general), 
have  been  associated  by  different  investigators  with  cancer 
as  predisposing  causes.  Some  hold  that  the  same  underlying 
diathesis  which  renders  a  person  susceptible  to  tuberculosis  or 
psoriasis,  predisposes  such  an  individual  to  malignant  disease. 
The  local  manifestations  of  these  diseases,  as  well  as  of  syphilis, 
in  which  diathesis  plays  no  part,  are  thought  to  predispose  the 
subject  to  the  development  of  cancer  upon  the  site  of  the 
lesion. 

The  explanation  of  the  causal  relationship  between  cancer 
and  these  local  manifestations  of  other  diseases  has  not  been 
definitely  determined.  By  some  it  is  thought  to  rest  upon  the 
basis  of  a  certain  tissue  susceptibility;  by  others  there  is  sug- 
gested the  same  or  a  closely  related  essential  cause ;  and  by  still 
others  the  irritation  theory  is  brought  into  play,  as  in  the  case 
of  an  old  lupus  scar  or  a  long-standing  tubercular  sinus. 

Whatever  the  explanation,  the  fact  remains,  as  pointed  out 
under  Predisposing  Causes  (Section  IV,  Chapter  2),  and 
as  illustrated  in  some  of  the  case  reports  appended,  cancer 
is  not  infrequently  superimposed  upon  local  manifestations  of 
other  diseases,  upon  the  tissue  subjected  to  chronic  irritating 
discharges,  or  upon  the  scar  tissue  which  results  from  such  local 
lesions,  particularly  when  subjected  to  irritation. 

Further  consideration  of  the  possible  influence,  as  predis- 
posing factors,  of  local  manifestations  of  other  diseases  is  re- 
served for  the  discussion  of  inflammation  and  irritation. 


PROPHYLAXIS  225 

SOURCES    OF    CHRONIC    INFLAMMATION    AND    IRRITATION 

The  fact,  as  stated  in  Section  IV,  Chapter  2,  page  126,  that  a 
large  part  of  the  work  of  the  Imperial  Cancer  Research  Fund  of 
London  is  directed  toward  discovering  the  explanation  of  the 
association  between  many  forms  of  cancer  with  chronic  irrita- 
tion, gives  an  idea  of  the  importance  which  is  attached  to  thia 
predisposing  factor  in  the  production  of  cancer. 

The  manifold  character  of  irritants — which  may  be  chemi- 
cal, mechanical,  actinic,  or  bacterial — is  noted,  and  a  large 
number  of  experiments  and  observations  have  been  made  in 
this  connection. 

It  may  be  stated  in  general  terms  that,  for  purposes  of 
prophylaxis,  so  far  as  cancer  is  concerned,  no  matter  what  the 
nature  of  the  irritant,  when  its  effects  are  sufficiently  marked 
to  become  a  menace,  the  cause  of  irritation  should  be  obviated, 
whether  it  be  a  chemical  irritant  associated  with  occupation, 
an  actinic  irritation  arising  from  X-ray  or  other  burns,  me- 
chanical irritation,  from  the  friction  of  wearing  apparel,  or 
bacterial,  as  giving  rise  to  certain  local  predisposing  lesions. 

There  are  very  few  portions  of  the  body  which  are  exempt 
from  one  or  another  of  the  various  kinds  of  irritation. 

The  upper  part  of  the  head  furnishes  an  excellent  illustration, 
of  the  danger  of  chronic  irritation  (see  case  reports  appended, 
ISTos.  I,  II,  III,  IV,  and  V).  As  is  well  known,  the  upper  part 
of  the  head,  or  above  the  mouth,  is  not  so  frequently  the  seat  of 
malignant  neoplasms  as  is  the  part  which  involves  the  mouth 
and  the  upper  part  of  the  neck.  This  difference  is  traceable, 
at  least  in  a  measure,  to  the  relative  paucity  of  blood  supply  of 
the  scalp,  forehead,  and  cheek.  Yet  in  this  region,  as  illustrated 
by  the  cases  cited  below,  apparently  very  insignificant  lesions, 
when  subject  to  irritation,  may  eventuate  in  serious  and  fatal 
cancer. 

The  mouth  is  a  common  seat  of  malignancy,  because  of  the 
wide  possibility  of  irritation.  The  presumptive  influence,  in 
this  connection,  of  leukoplakia  and  syphilis  has  already  been  in- 
dicated. Another  very  common  source  of  irritation  associated 
with  cancer  of  the  lip  and  tongue  arises  from  smoking.  The 
pipe,  cigar,  or  cigarette,  being  always  held  in  the  same  position, 
by  mechanical  irritation,  by  burning,  or  perhaps,  as  suggested 
by  Lazarus-Barlow,  by  radioactivity,  seems  to  initiate  the  cell 
proliferation  which  eventuates  in  cancer.  It  is  important,  there- 
fore, for  persons  who  cannot  resist  the  inclination  to  smoke,  to 
vary  the  position  of  the  pipe,  cigar,  or  cigarette,  and  thus  di^ 
minish  the  possible  danger  of  cancer. 


226  THE    CANCER    PROBLEM 

Cancer  of  the  tongue  and  buccal  cavity  is  often  noted  in  per- 
sons whose  decayed  and  jagged  teeth  cause  abrasions  and 
chronic  irritation  of  these  parts.  Malignant  epulis  and  other 
malignant  neoplasms  of  the  alveolar  process  are  often  seen  in 
persons  with  ill-fitting  crown-and-bridge  w^ork  or  dental  plates, 
or  in  those  whose  teeth  are  neglected  and  in  bad  condition.  In 
such  cases  the  dentist  may  play  an  important  part  in  the  pre- 
vention of  cancer,  and  should  cooperate  with  the  medical  pro- 
fession in  the  campaign  of  education  with  regard  to  such 
matters. 

The  female  breast  is  to  be  particularly  well  guarded  with 
reference  to  the  prevention  of  cancer  by  attention  to  the  pre- 
disposing factors  which  involve  this  organ.  Where  the  glandu- 
lar tissue  has  been  largely  supplanted  by  the  connective  tissue 
of  suppurative  mastitis,  a  favorable  condition  for  cancer  forma- 
tion apparently  develops.  Fissures  of  the  nipple,  the  inflam- 
matory aifection  of  the  areola  and  nipple  known  as  Paget's 
disease,  and  areas  subjected  to  chronic  irritation  by  the  corset, 
are  particularly  apt  to  become  the  seat  of  cancerous  change. 
Attention  to  these,  as  well  as  to  severe  acute  trauma  of  any  part 
of  the  breast,  will  do  much  toward  diminishing  the  risk  of  mam- 
mary cancer. 

Other  parts  of  the  surface  of  the  body  are  subject  to  malig- 
nant neoplasms  apparently  resulting  from  or  associated  with 
insignificant  conditions.  For  example,  a  case  of  sarcoma  of  the 
foot  is  reported  ^  as  having  developed  following  a  blood-blister 
caused  by  wearing  a  tight  boot.  Five  cases  of  melanotic  sar- 
coma of  the  foot  are  reported  in  Kafirs  -  whose  feet  were  full  of 
deep  cracks. 

The  association  between  cancer  and  chronic  inflammation  or 
irritation  is  fairly  easy  of  demonstration  upon  the  surface  of 
the  body.  In  the  internal  organs  it  is  more  difficult,  for  ob- 
vious reasons,  and  for  some  positions,  for  example,  in  the  brain, 
the  retina,  and  the  new-born  child,  it  is  hardly  conceivable  that 
irritation,  in  the  tangible  sense  here  considered,  plays  any  part 
whatsoever.  It  does  not  follow,  however,  that  the  tissues  are 
incapable  of  irritating  one  another  because  of  some  disturbance 
of  cell  equilibrium,  whether  by  internal  secretion,  or  by  other  as 
yet  unknown  cause. 

Cervical  tears  and  metritis  are  commonly  associated  with 
cancer  of  the  uterus.     Chronic  constipation,  with  fecal  impac- 

^  Brit.  Med.  Jour.,  February  11,  1882;  also  Annals  of  Surgery,  March, 
1898. 

*  Henson,  W.  Warner. — ' '  Cancer  in  Kafirs :  Suggested  Cause, ' '  Guy 's 
Hospital  Gazette,  March  26,  1904,  N.  S.  18,  p.  1.31. 


PROPHYLAXIS  227 

tion  in  the  rectum,  and  the  careless  manipulation  of  the  douche 
nozzle,  are  common  causes  of  irritation  in  the  presence  of  me- 
tritis and  cervical  tears. 

In  cancer  of  the  stomach  chronic  gastritis,  with  its  sequel, 
chronic  gastric  ulcer,  mechanical  lesions  of  the  gastric  mucosa^ 
constant  pressure  in  the  gastric  region,  as  is  experienced  hj 
shoemakers,  weavers,  and  similar  workers,  whose  tools  con- 
stantly press  against  the  region  over  the  stomach,  and  pressure 
bj  the  corset  in  women  who  are  given  to  the  practice  of  tight 
lacing,  are  some  of  the  predisposing  factors  mentioned  in  con- 
nection with  gastric  cancer.  The  importance  of  gastric  and  in- 
testinal ulcer  in  the  causation  of  gastro-intestinal  cancer  is  a 
disputed  question.  Boas,  Ewald,  Hansen,  Rosenheim,  Lebert, 
and  others,  estimate  the  frequency  of  the  transformation  of 
simple  ulcer  into  cancer,  as  five  per  cent.  Mayo,  Moynihan, 
Rodman,  and  others,  have  found  a  history  of  previous  ulcer  in 
as  high  as  fifty  per  cent,  of  cases  of  cancer  of  the  stomach. 
Paterson,  on  the  other  hand,  does  not  recognize  this  relation- 
ship. 

Cancer  of  the  liver,  gall-bladder,  bile-ducts,  and  pancreas  is 
thought  to  be  initiated  in  a  large  proportion  of  cases  in  conse- 
quence of  the  irritation  caused  by  calculi.  Zenker  (1889) 
found  a  history  of  calculi  in  84.5  per  cent,  of  all  cases  of  he- 
patic carcinoma;  Beadles  (Cancer  Hospital,  London,  1905), 
in  one  hundred  per  cent. ;  Miodowski,  in  only  33^  per  cent. 

The  facts  that  bile-stones  associated  with  cancer  of  the  liver 
occur  almost  exclusively  in  women,  and  that  the  cause  of  bile- 
stone  formation  is  generally  referred  largely  to  tight  lacing, 
indicate  that  the  abuse  of  the  corset  is  indirectly  connected  with 
the  development  of  cancer  of  the  liver. 

The  importance  of  giving  due  attention  to  the  predisposing 
factors  discussed  in  the  foregoing  pages  might  be  emphasized  , 
by  a  multiplicity  of  cases  of  cancer  in  different  parts  of  the 
body.  The  following,  however,  selected  because  the  lesions 
involved  some  portion  of  the  skin  and  mucous  membrane,  and 
hence  were  visible  and  palpable,  will  suffice. 

Cases  are  selected,  in  so  far  as  is  possible,  which  represent  the 
apparently  insignificant  beginning  as  well  as  the  direful  eventu- 
ation  of  the  condition.  In  many  instances,  for  obvious  reasons, 
it  has  been  impossible  to  represent  the  beginning  and  the  end 
in  the  same  case.  The  series  is  made  complete,  however,  by 
the  presentation  of  similar  conditions,  at  a  given  stage,  in 
different  individuals.  In  one  or  two  cases  both  the  early  and 
the  late  stages  of  the  disease  appeared  in  the  same  individual 
coincidentally,  but  in  different  localities. 


228  THE  CANCER   PROBLEM 

It  is  to  be  emphasized  that  some  of  the  cases  present  condi- 
tions which,  in  themselves,  are  of  no  special  interest,  becoming 
important  only  in  proportion  to  their  liability  to  eventuate  in 
something-  more  serious. 

In  each  case  of  cancer  the  clinical  diagnosis  was  verified  by 
microscopical  examination.  Unnecessary  details  are  omitted 
for  the  sake  of  brevity,  but  the  cases  are  so  protocolled  that 
future  reference  is  possible. 

For  purposes  of  convenience  the  cases  are  grouped  largely 
according  to  site-incidence  rather  than  to  the  histologic  char- 
acteristics of  the  lesions. 

CASE  REPORTS. 

Case  I. — G.  R.,  male,  aged  42,  physician.  In  the  left  tem- 
poral region  is  a  small  fibroma;  in  the  center  of  the  forehead  is 
a  small  capillary  angioma;  on  the  right  side  of  the  forehead  is  a 
small  pigniente'd  spot.  The  angioma  is  not  elevated  above  the 
surface,  and  therefore  is  not  of  as  much  significance,  as  regards 
possible  serious  results,  as  is  that  in  Case  II. 

Even  flat  angiomata,  however,  when  subjected  to  constant 
irritation,  may  undergo  malignant  change. 

The  angioma  in  this  case  was  removed  by  a  confrere,  without 
a  scar,  by  means  of  mercurial  caustic. 

Case  II. — H.  C,  male,  aged  28,  physician.  In  contradis- 
tinction to  Case  I,  this  patient  has  a  small  elevated  angioma  on 
the  forehead.  Subjected  to  chronic  irritation  or  acute  injury 
this  is  liable  to  undergo  malignant  change. 

Case  III. — H.  S.,  male,  aged  18  months.  Shortly  after  birth 
a  small  elevated  angioma  appeared  near  the  inner  canthus  of 
the  left  eye.  It  grew  rapidly,  projecting  over  and  completely 
obstructing  the  eye.  It  was  treated  by  the  physician  consulted 
by  means  of  caustic  applications.  Following  this  there  was 
ulceration,  which  did  not  heal,  and  the  growth  continued  to 
increase  in  size. 

The  angiomatous  mass  was  removed  in  toto.  Serious  hemor- 
rhage was  obviated  by  the  use  of  silk  threads,  so  placed  as  to 
partition  off  the  angiomatous  mass.  Into  each  partition  was 
injected  a  small  quantity  of  carbolic  acid.  This  caused  com- 
plete coagulation,  en  masse,  of  the  blood  within  the  tumor, 
after  which  the  threads  were  withdrawn.  When  contraction  of 
the  growth  had  taken  place  the  entire  mass  was  easily  r,emoved. 
Pathological  examination  showed  distinct  angiosarcoma. 

The  child,  at  the  end  of  six  years,  is  perfectly  well,  witk 
practically  no  deformity. 


PROPHYLAXIS  229 

Case  IV.— M.  O'C,  female,  aged  73.  Epithelioma  of  left 
cheek,  of  twelve  years'  duration,  originating  upon  the  site  of  a 
hum  from  a  match.  A  white  scar  resulted  from  the  burn.  Six 
jears  later,  when  repeatedly  asked  if  the  scar  was  due  to  small- 
pox, and  when  told  that  if  she  would  make  it  bleed  it  would 
disappear,  she  began  to  pick  at  and  scratch  it  until  it  bled.  As 
the  scab  would  form  she  would  lift  it  off,  not  allowing  the  place 
±0  heal  naturally.  As  a  result  of  this  an  ulcer  formed,  which 
grew  to  such  proportions  that  she  sought  medical  treatment. 
From  1905  to  1909,  with  an  interim  of  a  month  or  so  during 
these  four  years,  she  received  X-ray  treatment  twice  a  week. 
The  growth  continued  to  extend.  One  year  before  admission  to 
the  hospital  two  other  small  grovii;hs  appeared  near  the  first. 

The  cancer,  when  we  first  saw  it,  was  irremovable,  and  palli- 
ative operation  in  a  woman  of  this  age,  with  such  extensive 
involvement,  could  hardly  be  expected  to  accomplish  much. 
An  ascitic  fluid  was  employed  for  a  time,  after  the  method  of 
Hodenpyl,  but  without  effect.  Radiogelatin  was  also  used  for 
a  short  time,  but  the  patient  objected  to  the  reaction  caused  by 
these  injections,  and  the  treatment  was  discontinued  before 
having  been  given  a  fair  test  in  this  case. 

Thorough  removal  of  the  growth  in  the  beginning  would  un- 
doubtedly have  resulted  in  eradication  of  the  disease ;  or,  better 
still,  removal  of  the  scar  left  by  the  burn,  which  was  subjected 
to  constant  irritation,  would  have  prevented  the  cancer. 

The  case  illustrates  the  local  nature  of  so  many  malignant 
growths  above  the  mouth.  We  have  here  a  terrific  involvement, 
of  many  years'  duration,  with  absolutely  no  metastasis  in  any 
other  part. 

The  patient  has  lately  returned  to  the  hospital  begging  for 
relief  during  her  last  days. 

Case  V. — J.  R.  P.,  male,  aged  72.  Epithelioma  of  frontal 
region,  with  metastasis  in  parotid  region,  in  cervical  glands, 
and  in  lung.  The  upper  nodule  is  a  recurrence  in  the  location 
of  the  primary  growth.  This  first  appeared  as  a  small  nodule 
in  the  skin,  left  side  of  forehead.  It  was  cauterized  by  caustic 
applications,  after  which  it  healed.  Soon  afterward  another 
nodule  appeared  lower  down,  nearer  the  inner  canthus  of  the 
eye.  Shortly  after  the  appearance  of  this,  recurrence  took  place 
in  the  scar  of  the  caustic  treatment  of  the  first.  Metastasis  then 
appeared  in  the  parotid  region,  which  represents  the  patient's 
condition  when  he  first  consulted  me.  Examination  revealed 
involvement  of  the  cervical  glands,  and  operation  proved  that 
there  was  an  extension  of  the  metastatic  process  to  the  lung. 


230  THE   CANCER    PROBLEM 

Palliative  treatment  was  all  that  was  possible.  Patient  died 
from  internal  metastasis  June  9,  1908, 

We  have  in  this  case  a  history  of  early  and  terrific  recurrence 
and  metastasis  (within  seven  months  of  the  appearance  of  the 
primary  growth  upon  the  forehead)  arising  from  a  tinij  spot 
in  the  region  above  the  mouth,  a  growth  which  ordinarily  would 
presumably  be  easily  removable  by  the  various  dermatological 
measures  often  employed.  Radical  removal  by  surgical  means 
might  have  been  follow'ed  by  recurrence,  inasmuch  as  some  cases 
of  great  malignancy  seem  to  recur,  no  matter  what  is  done,  but 
certainly  the  chances  of  such  a  contingency  would  have  been 
greatly  lessened  by  a  clean-cut  excision  of  the  primary  growth 
when  first  noticed,  with  a  safe  margin  of  healthy  tissue  all 
around. 

Case  VI. — B.  G.,  female,  aged  46.  Epithelioma  of  orbit 
and  adjacent  structures,  involving  eyeball  and  extending  to 
the  dura  mater.  The  condition,  which  was  of  eight  years'  dura- 
tion, began,  according  to  the  history,  as  a  small  ulcer  on  the 
lower  lid,  following  a  local  diphtheritic  infection  during  an  at- 
tack of  diphtheria.  It  developed  slowly  at  first,  and  very  fast 
for  about  one  year  before  admission  to  the  hospital.  ISTo  treat- 
ment whatever  was  received,  except  with  washes,  salves,  etc., 
during  the  eight  years  previous  to  admission. 

In  April,  1909,  the  entire  growth  was  removed,  including 
the  contents  of  the  orbit,  together  with  its  inner  wall,  down  to 
the  dura  mater.  The  wound  was  packed  with  gauze  and  al- 
lowed to  granulate  preparatory  to  doing  a  plastic  operation. 
A  subsequent  slight  recurrence  necessitated  a  second  operation, 
when  an  area  of  the  dura^  about  the  size  of  a  ten-cent  piece, 
which  was  involved,  was  removed,  exposing  the  brain.  For  a 
time  the  cerebrospinal  fluid  came  from  the  wound.  Finally, 
however,  the  area  granulated  over.  Plastic  operation  was  per- 
formed at  later  date. 

There  are  no  signs  of  recurrence  at  the  present  time,  nearly 
five  years  after  operation.  In  a  letter  the  patient  says  she  is 
"enjoying  perfect  health." 

Case  VII.^ — H.  B.,  male,  aged  74.  Epithelioma  of  the  tip  of 
nose  and  left  side  of  cheek,  just  below  the  eye,  extending  about 
one  and  a  half  inches  from  the  nose.  This  began  five  years 
before  admission  as  a  small  wart-like  excrescence,  easily  re- 
movable. Six  months  later  a  growth  under  the  eye  developed 
from  a  similar  beginning,  and  was  also  easily  eradicable.  The 
patient,  in  this  case  as  in  the  preceding,  neglected  to  seek 
medical  advice  until  the  conditions  reached  the  proportions 
described. 


PROPHYLAXIS  231 

Complete  and  tliorongh  excision  of  the  epithelioma  was 
resorted  to,  followed  by  a  plastic  operation. 

The  patient  promised  to  return  upon  the  slightest  evidence 
of  a  recurrence,  and  inasmuch  as  I  have  heard  nothing  from 
him  for  more  than  two  years  I  take  it  that  he  has  had  no  further 
trouble.     He  has  moved  out  .of  the  city.     Address  unknown. 

Case  VIII. — J.  S.  R.,  male,  aged  69.  Epithelioma  of  nose, 
face,  orbit,  and  superior  maxilla,  which  began  in  1888  as  a 
tiny  nodule  on  the  side  of  the  nose.  Instead  of  being  eradicated 
completely  by  thorough  excision,  this  was  treated  with  caustics, 
curetting,  and  later  with  X-rays,  despite  all  of  which  treatment 
it  recurred  again  and  again. 

In  February,  1910,  an  extensive  operation  was  performed 
as  a  palliative  measure.  The  entire  contents  of  the  orbit, 
the  bony  orbit,  the  nasal  bones,  and  the  upper  part  of  the 
superior  maxilla  of  the  left  side,  were  removed  and  the  cavity 
was  packed  with  a  mild  iodoform  gauze,  benzoin,  shellac,  and 
nosophen  powder. 

Pain  was  greatly  relieved,  the  fetor  and  discharge  were 
lessened,  and  the  consequent  discomfort  to  the  patient  and  his 
family  ameliorated.  The  patient  was  still  alive  in  November, 
1910,  but  was  gradually  growing  weaker. 

Case  IX. — M.  F.  P.,  male,  aged  50.  Epithelioma  of  lower 
lip.  This  case  is  an  interesting  illustration  of  what  thorough 
surgery  will  accomplish  in  a  person  evidently  predisposed  to 
the  development  of  cancer.  Twenty-seven  years  before  I  saw 
him  a  small  growth  appeared  on  the  lip,  a  little  to  one  side. 
This  primary  growth  was  thoroughly  removed,  together  with 
the  glands  of  the  neck,  by  the  late  Dr.  Andrew  J.  McCosh.  For 
all  these  years  the  patient  has  remained  perfectly  free  from  can- 
cer. The  small  growth  for  which  he  consulted  me  could  not  be 
called  a  recurrence.  This  was  removed.  Reasoning  from 
analogy,  the  patient  will  be  free  from  cancer,  unless  another 
new  neoplasm  makes  its  appearance. 

Case  X. — T.  W.,  male,  aged  48.  Epithelioma  of  the  face 
and  neck,  recurrent  from  very  small  growth  on  the  lower  lip. 
The  primary  growth  was  removed  by  the  surgeon  who  was  con- 
sulted in  the  early  stage,  three  years  before  admission  to  the 
New  York  Skin  and  Cancer  Hospital,  but  the  cervical  glands 
were  not  removed.  This  case  is  the  antithesis  of  Case  IX.  In 
a  very  short  time  after  the  removal  of  the  growth  there  was  a 
tremendous  involvement  of  the  glands  of  the  neck,  with  internal 
metastasis.  When  admitted  to  the  hospital  the  patient  was  in 
such  an  advanced  stage  of  the  disease  that  no  operative  inter- 
ference was  warrantable.     He  died,  about  a  week  after  admis- 


232  THE   CANCER    PROBLEM 

sion,  of  metastasis,  the  original  site  of  the  growth  being  per- 
fectly healthy. 

This  case  emphasizes  admirably  the  importance  of  removing 
the  glands  of  the  neck  in  every  case  of  cancer  of  the  lovt^er  part 
of  the  face  and  mouth,  unless  there  are  some  definitely  contra- 
indicative  circumstances,  such  as  extreme  age  or  a  lowered  state 
of  vitality  which  would  render  such  an  operation  absolutely 
hazardous. 

Case  XI. — R.  R.,  female,  aged  5  years.  Sarcoma  of  face, 
extending  from  the  lip  as  the  primary  seat.  First  seen  at  the 
New  York  City  Children's  Hospitals  and  Schools,  Randall's 
Island,  December  2,  1909.  One  year  before  admission  to  the 
hospital  the  patient  noticed  a  small  swelling  upon  the  upper 
lip,  said  to  look  like  a  birth-mark.  This  continued  to  develop, 
and  the  growth  was  removed  at  Mt.  Sinai  Hospital.  Following 
this  the  patient  was  treated  at  the  New  York  Hospital  for  Rup- 
tured and  Crippled  for  eight  months  with  the  mixed  toxins  of 
Streptococcus  erysipelatosus  and  Bacillus  prodigiosus  (Coley's 
Fluid),  without  benefit.  The  patient  was  subsequently  removed 
to  Randall's  Island. 

According  to  the  history  obtained  from  the  mother,  the  fam- 
ily physician,  who  was  consulted  before  the  admission  of  the 
patient  to  any  hospital,  incised  the  growth  on  the  lip,  first  from 
the  outside,  then  from  the  inside,  and  irrigated  at  frequent  in- 
tervals. The  rapid  development  of  the  growth  to  a  fatal  issue 
within  one  year  serves  to  emphasize  the  danger  of  cutting  into  a 
malignant  growth.  In  view  of  the  generally  accepted  belief  in 
the  auto-infectivity  of  cancer  ^  it  is  reasonable  to  suppose  that 
the  growth  was  hastened  in  this  case  by  the  incision  of  the 
tumor. 

The  patient  received  only  palliative  treatment  at  Randall's 
Island,  where  she  died  shortly  after  admission. 

Case  XII. — V.  M.  W.,  male,  aged  58.  Epithelioma  of  ear, 
inside  concha.  Advanced,  but  removable.  Condition  began  as 
a  small  nodule,  first  noticed  about  three  months  before  he  con- 
sulted mo.  This  was  excised,  but  early  recurrence  followed. 
X-ray  treatment  was  then  instituted  and  continued  for  five 
weeks,  several  times  a  week,  but  proved  no  check  to  the  develop- 
ment of  the  growth.  His  physician  then  told  him  to  go  to  the 
country  for  a  vacation  in  order  to  build  up  his  general  health, 
so  that  the  local  condition  would  yield  more  readily  to  the 
X-ray  treatment.  The  patient  came  to  New  York  and  con- 
sulted me. 

1  Bainbridge. — ' '  Metastases  Following  Incision  of  a  Sarcoma, "  N.  Y. 
Polyclinic  Journal,  January,  1908,  p.  17. 


PROPHYLAXIS  238 

The  entire  auricle,  middle  ear,  and  part  of  the  mastoid  proc- 
ess were  involved.  All  the  diseased  tissue,  including  the  drum 
membrane,  periosteum  of  the  bones  inclosing  the  external  audi- 
tory canal,  and  part  of  the  mastoid  process  was  removed,  the 
glands  below  the  ear  being  extirpated  first.  Convalescence  was 
somewhat  prolonged  by  the  existence  of  otitis  media,  but  was 
eventually  perfect,  and  the  patient  has  remained  well  for  more 
than  four  years,  which  have  elapsed  since  the  operation. 

Case  XIII. — B.  H.,  male,  aged  93.  Epithelioma  of  right 
auricle,  of  ten  years'  duration.  The  ulcerating  growth  involved 
the  entire  auricle  and  contiguous  post-auricular  area.  This 
extensive  and  very  painful  condition  had  its  beginning  in  a 
small  pimple  at  the  masto-auricular  junction.  The  patient  con- 
stantly picked  and  irritated  the  growth  until  it  underwent 
malignant  change.  For  six  years  no  medical  aid  was  sought, 
then  the  physician  consulted  employed  X-ray  treatment  for 
about  one  year  without  permanent  benefit.  Kadium  was  sys- 
tematically used  by  another  physician  for  about  two  months, 
again  without  benefit,  and  with  so  much  pain  that  it  was  aban- 
doned. When  first  seen  by  me  the  involvement  was  so  extensive 
that  operation  in  so  old  a  patient  was  considered  futile.  He 
was  put  on  the  Enzyme  Treatment  (Case  51),  but  after  three 
months  he  insisted  upon  the  discontinuance  of  the  injections  be- 
cause of  the  pain  which  they  caused.     Died  December,  1909. 

Case  XIV. — C.  S.,  male,  aged  56.  Epithelioma  of  the  left 
ear,  extensive  and  advanced.  I^ine  years  before  consultation 
the  patient  was  burned  upon  the  ear  with  a  hot  cinder.  Before 
this  had  entirely  healed  he  received  a  blow  upon  the  ear,  follow- 
ing which  there  developed  the  growth  which  eventuated  in  the 
condition  described.  A  salve  was  used  upon  the  ear  by  the  first 
physician  consulted.  The  treatment  was  employed  for  ten 
months,  during  which  time  the  growth  steadily  progressed. 
The  auricle  was  then  partly  removed,  which  doubtless  involved 
the  cutting  into  of  the  cancerous  tissue.  At  any  rate,  this  did 
not  eradicate  the  trouble,  and  one  year  later  the  entire  auricle 
was  removed.  Recurrence  took  place  after  an  interim  of  a 
year,  and  the  physician  then  consulted  employed  a  caustic 
paste.  Despite  all  this  treatment  the  growth  continued  until, 
when  first  seen  by  me,  the  enormous  involvement  was  found. 
Upon  operation  this  proved  to  be  very  deep,  involving  the 
entire  mastoid  process,  parotid  gland,  part  of  the  parietal  bone, 
facial  nerve,  and  the  overlying  soft  tissue.  The  structures  in- 
volved were  removed  practically  in  toio,  though  it  was  not 
thought  possible  to  remove  all  of  the  disease.     The  dura  was 


^34  THE   CANCER    PROBLEM 

exposed  for  an  area  two  and  a  half  inches  in  diameter.     The 
extensive  wound  was  packed  and  allowed  to  granulate. 

At  the  present  time,  after  more  than  two  years,  there  is  a 
small  nodule  of  recurrence  at  the  upper,  and  one  at  the  lower 
part  of  the  sear  area,  insignificant  in  size  and  causing  no  symp- 
toms.    (These  have  been  removed.) 

Case  XV. — G.  S.,  female,  aged  18  months.  Nevus  on  shoul- 
der; angiosarcoma  of  forearm,  earl}'  stage,  about  the  size  of  a 
silver  quarter.  The  nevus  on  the  shoulder,  which  was  elevated 
above  the  surrounding  skin  surface,  represented  the  precancerous 
stage  of  the  angiosarcoma  of  the  forearm.  The  latter  had 
exactly  the  same  beginning  as  the  former,  but  developed  to  the 
proportions  found  before  its  removal.  The  presumption  is  that 
the  nevus  on  the  shoulder  would  have  run  the  same  course  had 
it  been  removed  before  malignant  degeneration  began.  After 
an  interim  of  three  years  there  has  been  no  return  of  either 
growth.  Either  one,  neglected,  would  doubtless  have  had  the 
same  ultimate  history  as  the  similar  growth  in  the  next  case. 

Case  XVI. — A.  W.,  male,  aged  55.  Spindle-celled  sarcoma 
of  right  shoulder,  advanced  stage.  This  developed  from  a  small 
elevated  angioma,  situated  in  the  same  relative  position  as  the 
nevus  on  the  shoulder  in  the  preceding  case.  As  a  schoolboy 
the  patient  noticed  this  little  birth-mark,  which  was  so  situated 
that  his  suspender  buckle  rubbed  over  it,  and  constantly  irri- 
tated it.  This,  in  addition  to  a  number  of  injuries,  seemed  to 
initiate  malignant  degeneration ;  at  any  rate,  by  the  time  he  was 
fifteen  years  of  age  there  was  a  tumor  at  the  site  the  size  of  a 
hazelnut.  Removal  at  that  time,  with  a  safe  margin  of  healthy 
tissue,  would  in  all  probability  have  resulted  in  complete  cure. 
This  was  not  done,  however,  until  later,  when  the  growth  had 
assumed  much  larger  proportions.  A  conservative  operation 
was  then  performed  by  the  surgeon  consulted,  but  in  spite  of 
this,  recurrence  soon  followed,  the  neoplasm  developed  rapidly, 
and  when  the  patient  was  first  seen  by  me  the  deep  structures  in 
the  neck,  extending  down  between  the  main  trunks  of  the  bra- 
chial plexus,  were  involved.  The  enormous  mass,  with  its  deep 
extensions,  was  completely  extirpated  in  January,  1908.  The 
patient  remained  apparently  well  for  several  months  after  this 
operation,  but  finally  died  of  internal  metastasis  September, 
1909. 

Case  XVII. — A.  F.  L.,  male,  aged  73.  Carcinoma  of  hand; 
recurrence  in  axilla  and  chest  wall.  Twenty-three  years  before 
admission  to  the  Skin  and  Cancer  Hospital,  in  November,  1909, 
a  small  f.apillomatous  nodule  appeared  on  the  dorsum  of  the 
left  hand.      For  five  years  this   received  no  treatment,  then 


PROPHYLAXIS  2S5 

caustics  were  employed,  and  later  X-rays  were  resorted  to, 
without  avail.  When  the  patient  entered  the  hospital  prac- 
tically the  entire  dorsum  of  the  left  hand  was  involved  in  the 
growth,  and  metastatic  deposits  were  found  in  the  chest  wall 
and  axilla.  The  forearm  was  amputated,  the  axillary  space 
was  cleared,  and  all  diseased  tissue  of  the  chest  wall  removed. 

At  the  present  time  the  patient  is  suffering  from  internal  me- 
tastasis, which,  however  unfortunate,  is  not  as  distressing  for 
the  patient  or  the  family  as  is  external  cancer. 

Case  XVIII. — E.  M.,  female,  aged  26.  Papilloma  of  hack. 
From  irritation  by  corsets  the  growth  is  beginning  to  undergo 
inflammatory  change,  which  is  a  precancerous  stage  of  cancer. 
With  continued  irritation,  malignant  degeneration  is  apt  to 
follow. 

Case  XIX. — M.  McG.,  female,  aged  70.  Epithelioma  of  left 
buttock ;  papilloma  of  right  shoulder.  This  case  represents  the 
precancerous  (shoulder)  stage,  and  the  cancerous  (buttock) 
actively  growing  stage,  in  the  same  host.  The  epithelioma  of 
the  buttock  began  as  an  insignificant  papilloma  like  the  one  on 
the  shoulder,  but  being  so  situated  that  it  was  subjected  to 
irritation  it  developed  into  a  growth  the  size  of  a  lemon. 
The  small  papilloma  on  the  shoulder  was  not  especially  irritated 
and  had  not  undergone  degeneration.  Both  excised.  Patient 
now  well,  four  years  after  operation. 

Case  XX. — M.  S.,  male,  aged  22.  Sarcoma  of  thigh  and 
groin.  From  a  starting  point  very  much  like  a  small  mole  the 
size  of  a  pea,  on  the  ankle,  which  remained  so  for  years,  then  be- 
gan to  grow,  recurrence  took  place  on  the  inner  aspect  of  thigh 
and  groin.  Seven  months  before  admission,  patient  was  treated 
with  Coley's  Fluid  preceding  and  following  removal  of  sec- 
ondary tumor  from  Scarpa's  triangle.  When  first  seen  by  me 
internal  metastasis  had  occurred. 

Multiple  sarcomata  of  leg  and  groin  removed.  Patient  died 
August  27,  1910. 

SUMMARY 

Actual  clinical  experience,  gained  from  the  study  of  hun- 
dreds of  cases  similar  to  those  presented  above,  has  convinced 
us  that  a  large  proportion  of  severe  and  perhaps  fatal  malig- 
nant neoplasms  may  be  traced  to  apparently  insignificant  and 
harmless  warts,  moles,  and  nevi,  which  are  subjected  to  irrita- 
tion of  one  kind  or  another,  and  which  are  easily  and  com- 
pletely removable  by  surgical  means. 

Rational  attention  by  physicians  and  laymen  to  these  seem- 
ingly inconsequent  conditions  would  undoubtedly  tend  to  lessen 


236  THE   CANCER    PROBLEM 

the  proportion   of  cases   of  irremovable   and   inoperable,   and 
consequently  fatal,  cancer. 

To  keep  a  watchful  overlook  of  all  patients  with  reference  to 
these  conditions  is  the  duty  of  every  physician  and  surgeon, 
because  it  forms  an  important  part  of  the  prevention  of  cancer. 


SECTION    IX 

THE   INVESTIGATION   OF    ''CANCER    CURES" 

DIVERSITY  OF  AGENTS  EMPLOYED  IN  THE  TREATMENT 

OF    CANCER 

The  remedial  agents  whicli  have  been  suggested  or  employed 
in  the  treatment  of  malignant  neoplasms  range  in  diversity  from 
green  frogs  and  witchcraft  to  "Christian  Science"  and  modem 
Surgery. 

It  is  not  to  be  inferred  that  the  dead  past  has  buried  its  dead 
in  this  matter;  on  the  contrary,  the  past  has  brought  to  the 
present  many  detachments  of  its  army  of  therapeutic  shades. 

Owing  to  our  continued  ignorance  of  the  etiology  of  cancer, 
we  find  in  the  midst  of  the  scientific  practice  of  the  twentieth 
century,  remnants  of  the  ignorance  and  superstition  of  the 
earliest  times. 

It  is  for  this  reason,  as  well  as  for  its  possible  historical 
interest,  that  it  has  seemed  worth  while  to  devote  some  con- 
sideration to  this  phase  of  the  cancer  problem. 

Furthermore,  the  treatment  of  cancer  conforms  more  or  less 
to  the  law  of  the  rhythm  of  motion.  Remedies  for  the  disease 
have  had  their  days  of  popularity,  their  lapses  into  oblivion, 
and  their  revivals.  In  some  instances  this  cycle  has  been  re- 
peated over  and  over  again.  This  applies  to  many  of  the  agen- 
cies which  have  been  employed  by  the  medical  profession,  as 
well  as  to  those  whose  use  has  been  confined  to  the  "cancer 
quacks." 

The  employment  of  such  diverse  measures  and  methods,  some 
of  which  are  absurd  and  many  of  them  harmful,  is  the  natural 
outcome  of  the  mystery  which  enshrouds  the  nature  and  cause 
of  cancer.  It  has  also  been  fostered  by  the  difiiculty  which  has 
always  been  experienced  in  differentiating  the  various  forms  of 
this  disease  from  the  dermatological  manifestations  of  certain 
other  maladies,  and  by  the  mistakes  in  diagnosis  which  have 
arisen  from  these  factors. 

If  the  various  so-called  cancer  cures  were  employed  only  in 

237 


238  THE   CANCER    PROBLEM 

hopeless  cases,  being  used  merely  as  adjuvants  or  as  last  resorts 
in  the  desperate  effort  to  alleviate  suffering,  and  if  they  were 
in  no  way  harmful,  nothing  would  need  to  be  said  concerning 
them.  Unfortunately,  however,  they  are  often  brought  into 
requisition  where  more  rapid  and  better  established  methods 
should  be  utilized.  They  form,  therefore,  the  settings,  in  many 
cases,  of  the  deplorable  pictures  of  tampering ,  which  are  so 
often  presented  to  the  surgeon,  the  cancer  hospital,  and  the 
"home  for  incurables." 

The  record  is  a  very  long  one  of  remedies  that  have  been 
employed  empirically,  discarded,  and  at  a  later  time  revived 
again  and  again  in  the  treatment  of  cancer.  So,  too,  with  agen- 
cies which  have  seemed  to  possess  some  scientific  reason  for 
their  advocacy. 

Wlien  new  "cures"  are  being  exploited,  or  when  old  methods 
are  being  revived,  it  is  but  natural  that  the  conservative  element 
of  the  medical  profession  should  remain  skeptical.  It  is  equally 
to  be  expected  that  more  or  less  unscrvipulous  individuals  within 
the  pale  of  medical  ethics  should  attempt  to  turn  to  their  own 
advantage  the  conscientious  efforts  of  those  who  are  endeavoring 
to  discover  some  non-surgical  method  of  curing  cancer.  The 
surgeon,  therefore,  Avho,  more  than  anyone  else  perhaps,  has  the 
duty  imposed  upon  him  of  dealing  with  this  state  of  affairs,  is 
unwilling  to  subject  his  operable  patients  to  experimentation 
with  non-surgical  methods  which  have  never  been  "tried  out" 
by  those  who  are  competent  to  judge  of  the  merits  of  such 
methods.  This  attitude  on  the  part  of  the  members  of  the 
medical  profession  upon  whom  so  great  a  responsibility  rests 
has  fostered  the  idea  with  many  la^Tnen  that  the  surgeon  is 
unwilling  to  test  non-surgical  methods  for  the  cure  of  cancer. 

As  Secretary  of  the  Department  of  Research  of  the  New 
York  Skin  and  Cancer  Hospital,  it  has  been  my  duty  to  receive 
and  investigate  many  proposed  "cures"  for  cancer,  and  to  cata- 
logue many  which  are  in  no  way  worthy  of  consideration.  From 
this  experience  I  have  come  to  realize  that  there  are  certain 
aspects  of  this  question  which  are  not  generally  understood, 
either  within  or  without  the  medical  profession. 

In  the  light  of  our  present  knowledge  concerning  cancer,  no 
surgeon  should  hesitate  to  urge  the  patient  to  employ  the  only 
means  at  our  command  which  offers  a  definite  hope  of  cure  from 
this  scourge — surgical  removal.  So  long  as  patients  are  willing 
to  be  operated  upon,  so  long  must  surgeons  operate,  until  some 
better  method  has  been  positively  established.  It  has  been 
established  by   experiment  that   all   the   consequences   can   be 


THE   INVESTIGATION   OF   "CANCER   CURES"     239 

avoided  by  cutting  out  the  pin-head  of  cancer  inoculated  into 
animals,  and  as  yet  only  by  cutting  it  out. 

In  the  meantime,  however,  those  who  have  at  their  command 
a  great  many  cancer  patients  will  have  a  sufficient  number 
who  are  unwilling  to  undergo  operation,  or  v/ho,  because  of 
some  complicating  condition,  are  inoperable  while  the  cancer  is 
yet  curable  if  surgical  intervention  were  feasible,  upon  whom 
new  measures  may  be  tested  with  that  degree  of  thoroughness 
which  constitutes  a  fair  test.  It  may  be  easily  seen  that  to 
make  such  tests  a  surgeon  must  have  a  large  number  of  patients, 
or  have  charge  of  a  hospital  with  special  provision  for  such 
cases. 

It  cannot  be  gainsaid  that  surgeons  who  are  daily  brought 
into  contact  with  a  large  number  of  cancer  patients,  and  hospi- 
tals which  have  ample  provision  for  such,  are  not  only  willing 
but  anxious  to  apply  the  scientific  test  to  seemingly  rational  new 
methods  of  treatment. 

The  surgeon,  however,  must  protect  his  patients  from  char- 
latanry, which  is  nowhere  so  rampant  as  in  the  treatment  of 
cancer.  He  must  make  certain  demands  of  the  one  who  pro- 
poses a  new  method  and  who  insists  upon  its  being  tried.  He 
must  have  at  his  command  the  time,  the  facilities,  and  the  funds 
for  such  a  test,  which  is  but  simple  justice  to  both  his  patients 
and  himself. 

It  may  be  said,  in  passing,  that  in  the  majority  of  instances 
the  surgeon  receives  no  assistance  from  the  originator  of  the 
proposed  remedy.  The  test  is  demanded,  with  no  seeming  real- 
ization of  what  it  implies,  and,  if  it  is  not  made,  the  charge  of 
professional  bias  is  urged. 


WHAT    THE    SUEGEON    HAS   A   RIGHT    TO    KNOW    OF   A 
PROPOSED    METHOD    OF    TREATMENT 

Before  subjecting  his  patients,  in  private  practice  or  in  hos- 
pital service,  to  experimentation  with  a  new  agent,  the  surgeon 
should  be  assured  of  certain  points  concerning  the  proposed 
remedy. 

First,  he  should  have  evidence  of  the  sincerity  of  purpose  of 
the  individual  who  proposes  the  new  method — that  his  object  is 
the  furtherance  of  scientific  research  and  the  amelioration  of 
suffering,  and  not  merely  the  replenishing  of  his  own  coffers. 

Second,  he  must  know  that  the  method  has  some  legitimate 
claims  to  a  basis  of  scientific  principle — that  it  is  not  merelv 


240  THE   CANCER    PROBLEM 

"inherited  from  generations  of  cancer  curers,"  or  ''handed  down 
to  the  family  from  the  Indians,''  as  is  sometimes  claimed. 

Third,  he  must  have  ample  assurance  that  the  method  offers 
a  reasonable  hope  of  doing  more  good  than  other  known  means, 
with  clear  proof  that  it  will  do  no  harm. 

Furthermore,  before  taking  up  the  investigation  of  a  cancer 
"cure,"  it  is  the  surgeon's  right  to  demand: 

(1)  That  the  composition  and  method  of  preparation  of  the 
proposed  remedy  be  given.  In  other  words,  no  one  should  be 
expected  to  test  a  secret  remedy.  It  is  but  fair  to  the  patient, 
to  the  possessor  of  the  remedy,  and  to  the  one  who  tests  it,  that 
the  alleged  efficacious  ingredient  or  ingredients  be  disclosed. 
Objection  is  generally  made  to  this  requirement  on  the  part  of 
the  possessor  of  the  "cure,"  but  the  one  who  tests  it  should 
not  yield  the  point.  In  the  event  of  the  "remedy"  being  of- 
fered for  a  price  there  is  no  guarantee  that  it  is  to  become  pub- 
lic property  if  not  disclosed. 

(2)  That  a  reasonable  scientific  theory  be  furnished  as  justi- 
fication for  the  desired  test,  or  that  authentic  clinical  evidence 
of  the  efficiency  of  the  method  in  treating  proved  cases  of  can- 
cer be  produced. 

Many  of  the  more  hopeful  of  the  remedies  which  have  been 
proposed  from  time  to  time  have  not  been  adequately  tested 
before  the  demand  has  been  made  upon  the  surgeon  or  hospital 
that  a  case  trial  be  given.  In  some  instances,  therefore  (notably 
the  Enzyme  Treatment  proposed  by  Beard),  the  requirement 
with  reference  to  clinical  evidence  is  waived  as  being  offset  by 
the  scientific  premises  upon  which  the  method  is  based.  In 
very  few  instances,  in  fact,  can  this  point  be  adhered  to,  for  the 
reason,  previously  suggested,  that  only  those  who  come  in  con- 
tact with  large  numbers  of  cancer  patients  can  make  adequate 
tests,  and  for  the  further  reason  that  the  originator  of  the  new 
method,  in  many  instances,  is  not  in  position  to  make  any  sort 
of  demonstration  of  his  theory.  This  is  one  of  the  chief  diffi- 
culties encountered  in  this  phase  of  cancer  research. 

At  the  New  York  Skin  and  Cancer  Hospital  there  is  a  stand- 
ing offer  of  a  monetary  remuneration  to  anyone  who  presents 
for  trial  a  non-surgical  method  for  the  cure  of  cancer  which 
will  stand  the  test  of  application  to  the  cancer  sufferer.  ISTatur- 
ally,  the  hospital  reserves  the  right  to  judge  of  the  merits  of  the 
claims  to  recognition ;  to  make  the  test  when  it  is  deemed  wise 
to  do  so ;  and  to  render  the  final  decision  as  to  the  value  of  the 
method.  In  addition  to  revealing  the  exact  formula,  the  sole 
condition  upon  which  such  a  test  is  made  is  that  the  proposed 


THE  INVESTIGATION  OF  "CANCER  CURES"  24.1 

method  offers  a  reasonable  hope  of  doing  more  good  than  any- 
thing known,  and  a  certainty  that  it  will  do  no  harm. 

There  are  on  file  something  like  sixty  "cures"  which,  in  one 
way  or  another,  we  have  been  importuned  to  try  in  the  wards. 
Some  of  these,  as  will  be  seen  later,  have  been  tried ;  some  are 
now  being  tried;  others,  after  due  consideration,  have  been  re- 
fused test,  while  still  others  have  been  so  plainly  of  the  "quack" 
type  that  nothing  more  has  been  done  than  catalogue  them  as 
matters  of  curiosity. 

From  the  list  of  proposed  "cures,"  which  includes  all  man- 
ner of  things,  from  "live  lobster  and  leek"  to  the  elaborately 
evolved  product  of  the  biological  chemist,  we  have  selected  from 
time  to  time  such  agents  as  seemed  to  meet  the  requirements 
above  stated.    Brief  details  of  some  of  these  tests  are  given. 


WHAT    CONSTITUTES   A   "FAIR   TEST" 

It  is  generally  conceded  that  sporadic  or  isolated  instances 
of  cure  of  any  disease  by  a  given  means  do  not  necessarily  serve 
to  indicate  the  successful  application  of  the  method  to  the  gen- 
eral run  of  cases.  This  applies  quite  as  forcefully  to  cancer  as 
to  any  other  disease.  It  is  also  quite  well  understood  that  there 
is  a  curved  line  of  betterment  in  the  majority  of  cases,  in  spite 
of,  rather  than  in  consequence  of  any  treatment.  Any  agent 
or  method  which  chances  to  be  employed  at  the  time  of  the 
ascending  curve  of  betterment  is  apt  to  receive  credit  for  such 
improvement. 

For  these  reasons  we  have  become  accustomed  to  the  idea  that 
proof  rests  only  in  accumulated  experience.  We  are  prone, 
therefore,  to  look  with  a  certain  degree  of  skepticism  upon  the 
claims  to  success  which  are  founded  upon  a  small  number  of 
clinical  records.  Yet  who  shall  say  just  what  that  number  must 
be  ?    By  what  standards  shall  the  fairness  of  a  test  be  measured  ? 

The  late  Dr.  Maurice  H.  Richardson  ^  held  that  "one  single 

total  disappearance  of  undoubted  breast  cancer  under  any  form 

of  non-operative  treatment  will  presage  success,  just  as  surely 

as  a  successful  man-flight  presaged  aviation."      But  what  of 

the  outlook  for  such  a  method  if,  succeeding  in  one  case,  it 

fails  in  one  hundred  cases  ? 

^ Eichardson,  Maurice  H. — "The  Operative  Treatment  of  Cancer  of  the 
Breast,"  Jour.  Am.  Med.  Assn.,  February  4,  1911,  p.  315. 


242  THE   CANCER    PROBLEM 

THE    ENZYME    TREATMENT 
(Trypsin    and   Amylopsin,   Plus   Regime") 

Dr,   John  Beard/  one  of  the  originators"   of  the  enzyme 

treatment  of  cancer,  accepts  one  case  of  recurrent  sarcoma,  in 
which  the  "remains  of  the  tumor  finally  shelled  out  'like  the 
kernel  of  a  nnt' "  under  the  enzyme  treatment,  as  an  un- 
doubted proof  of  the  correctness  of  the  theory  upon  which  the 
method  is  based,  and  consequently  as  proof  of  its  curative  value. 
At  the  same  time  he  rejects,  as  practically  no  test  at  all,  the 
painstaking  trial,  extending  over  three  years,  and  applied  in 
one  hundred  cases  at  the  New  York  Skin  and  Cancer  Hospital.^ 

The  question  then  naturally  arises:  ''What  constitutes  a 
'fair  trial'  of  a  given  method  ?" 

The  test  given  the  enz^one  treatment  at  the  New  York  Skin 
and  Cancer  Hospital,  according  to  our  ideas,  is  an  example  of  a 
"fair  test,"  by  which  is  meant  a  test  that  is  conducted  along 
scientific  lines,  justice  to  the  patient,  and  justice  to  the  theory 
upon  which  the  method  of  treatment  is  based,  being  at  all  times 
borne  in  mind. 

The  charges  have  been  made  of  the  various  tests  of  this 
method  that  they  were  not  made  with  a  sufficient  number  of 
cases  to  be  conclusive,  that  the  time  during  which  the  patients 
were  under  treatment  and  observation  was  too  short,  and  that 
the  test  was  begam  with  a  preconceived  notion  that  the  findings 
would  be  negative.  In  this  connection  it  is  interesting  to  read 
the  opinions  of  others  with  reference  to  our  test  of  this  method. 

The  British  Medical  Journal,'^  for  example,  referred  to  our 
report  as  follows:  "It  is  a  very  extensive  and  elaborate  docu- 
ment, with  carefully  tabulated  details  and  charts."  Czerny, 
before  the  Second  International  Conference  for  the  Study  of 
Cancer,  held  in  Paris  in  1910,  referred  to  our  test  of  the 
enzjTue  treatment  as  an  example  of  thoroughness  and  of  prog- 
ress by  negation.  Rowntree  ^  said :  "Any  doubts  that  may 
have  lingered  in  the  minds  of  those  who  thought  the  various 

1  Beard,   John. — "The   Enzyme   Treatment   of   Cancer,"   1911. 

2  ' '  Discussion  on  Non-Operative  Treatment  of  Cancer, ' '  Proc.  Koy.  Soc. 
Med.,   Therap.  Sect.,   1913. 

3  Bainbridge,  William  Seaman. — ' '  The  Enzyme  Treatment  for  Cancer, 
Scientific  Report  on  the  Investigations  with  Reference  to  the  Treatment 
of  Cancer,  Published  with  the  Authority  of  the  Committee  on  Scientific 
Research  of  the  New  York  Skin  and  Cancer  Hospital,  1909.  See  also: 
^ew  Tori;  Medical  Journal,  March  2,  1907;  Brit.  Med.  Jour.,  March  2, 
1907,  pp.  486  and  519;  Medical  Sccord,  July  17,  1909. 

iBrit.  Med.  Jour.,  July  24,  1909,  p.  218    (editorial). 
5  Rowntree,   Cecil. — Article  on  Tumors,  in   "A   System  of    Treatment," 
edited  by  Arthur  Latham  and  T.  Crisp  English,  1912. 


THE   INVESTIGATION   OF   "CANCER   CURES"     213 

details  of  the  treatment  had  not  been  sufficiently  extended,  must 
surely  have  been  finally  dispelled  by  the  report  published  by 
Dr.  William  Seaman  Bainbridge,  of  New  York."  ''This  re- 
port," he  continues,  "deals  with  the  results  obtained  in  a  large 
number  of  cases  of  cancer  in  which  the  trypsin  treatment  had 
received  a  most  thorough  and  painstaking  trial." 

The  test  under  discussion  was  made  under  the  personal  direc- 
tion of  the  author,  with  the  assistance  of  members  of  the  Re- 
search Staff  and  others.  It  included  more  than  a  hundred 
cases;  ^  it  extended  over  more  than  three  years;  every  detail 
was  carefully  observed ;  careful  records  were  kept,  and,  through- 
out, the  wishes  of  Dr.  Beard,  as  expressed  in  numerous  per- 
sonal communications  which  we  have  on  file,  were  observed. 
We  entered  upon  the  test  with  absolutely  open  minds,  and 
maintained  throughout  the  scientific  attitude  of  suspended 
judgment  pending  proof. 

Such  a  test  may  not  conform  to  the  ideas  of  fairness  which 
exist  in  the  mind  of  an  investigator  whose  work  has  been  along 
the  lines  of  Beard.  It  would  seem,  however,  that  nothing 
more  can  justly  be  expected  of  the  clinician,  who,  whether 
working  in  the  laboratory,  in  the  operating  room,  or  at  the 
bedside,  must  at  the  same  time  be  true  to  his  human  obliga- 
tion to  the  patient. 

It  is  to  be  regretted  that,  after  all,  such  a  test  is  considered 
no  test  at  all  by  the  originator  of  the  method,  but  we  feel  sure 
that  unbiased  readers  of  our  report  will  agree  that  the  test  of 
the  enzyme  treatment,  as  carried  out  at  the  New  York  Skin 
and  Cancer  Hospital,  is  an  illustration  of  a  "fair  test." 

In  an  address  on  the  treatment  of  inoperable  cancer  at  the 
International  Surgical  Conference,  Brussels,  1908,  Sir  Henry 
Morris  ^  said  that  Dr.  Beard  originally  supported  his  conten- 
tions by  two  experiments  on  mice.  According  to  Dr.  Beard, 
two  mice  suffering  from  Jensen's  carcinoma  exhibited  symp- 
toms after  the  injection  of  21/2  minims  of  1.5  per  cent,  solution 
of  trypsin,  which  Dr.  Beard  ascribed  to  intoxication  by  the 
"products  of  the  tumor  (an  alcohol?),  as  extracted  and  di- 
gested by  the  large  dose  of  trypsin."  The  tumors  were  found 
to  be  in  an  advanced  state  of  degeneration  and  necrosis.     No 

1  The  question  has  been  asked,  ' '  Why  was  the  method  tested  in  so  many 
cases!"  The  answer  is  twofold:  In  the  first  place,  through  the  wide 
publicity  given  in  the  secular  press  to  the  "wonderful  cures"  effected  by 
this  means,  patients  were  so  insistent  upon  being  treated  thereby  that  their 
requests  were  granted.  In  the  second  place,  Dr.  Beard  changed  his  instruc- 
tions from  time  to  time,  necessitating  an  increased  number  of  cases  in 
order  to  make  the  test  effectual. 

2  Morris,  Sir  Henry. — ' '  The  Treatment  of  Inoperable  Cancer, ' '  Second 
International  Surgical  Congress,  Brussels,  1908,  Vol.  II,  p.  295. 


244  THE   CANCER    PROBLEM 

evidence  was  advanced  that  degeneration  and  necrosis  did  not 
occur  independently  of  the  treatment.  As  a  matter  of  fact, 
ninety  per  cent,  of  tnmors  obtained  by  propagating  Jensen's 
carcinoma  exhibit  very  extensive  necrosis;  only  a  thin  shell  of 
healthy  tissue  may  remain. 

Mice  suffering  from  adenocarcinoma  mammge,  squamous- 
celled  carcinoma,  malignant  adenoma,  and  sarcoma,  were 
treated  with,  trypsin  in  many  series  of  experiments  in  the 
laboratories  of  the  Imperial  Cancer  Research  Fund.  Atten- 
tion was  paid  to  any  evidence  of  the  symptoms  of  intoxication, 
the  induction  of  necrotic  degeneration  and  inhibition  of  growth, 
and  of  the  specific  action  of  trypsin  on  cancer  tissue  while 
sparing  other  tissues,  as  described  by  Beard,  but  his  statements 
were  not  confirmed. 

"The  solutions,"  quoting  from  Morris,  'employed  by 
them  (even  when  diluted  to  the  strength  of  one  in  a  thou- 
sand and  injected  subcutaneously  into  mice  in  doses  of 
O'^'^S  to  0^^5)  produced  great  irritation  and  digestion  of  the 
overlying  skin,  so  that  in  the  space  of  one  to  three  hours 
after  injection  the  hair  over  the  site  of  the  fluid  fell  out  and  a 
large  moist  ulcer  formed.  Hence  the  doses  of  active  trypsin 
which  it  is  possible  to  give  to  mice  subcutaneously  without  local 
destruction  of  tissue,  and  which  are  perhaps  not  inferior  to  the 
doses  applied  to  the  treatment  of  the  human  subject,  are  so 
infinitesimal  that  the  absence  of  influence  on  the  growth  of 
tumors  in  mice  so  treated  is  not  astonishing.  To  meet  this 
objection  other  methods  of  application  were  sought.  Intra- 
peritoneal injection  is  also  followed  by  digestion  of  the  ab- 
dominal wall  at  the  site  where  the  fluid  collects,  the  destruction 
of  tissue  tending  to  advance  along  the  tract  of  the  needle  used 
to  inject  it.  In  their  highest  degree  the  consequences  are 
speedy  ulceration  of  the  abdominal  wall  and  escape  of  the  in- 
testines, which  appear  not  to  be  attacked.  Both  the  above 
methods  of  administering  trypsin  in  doses  sufficiently  great  to 
be  effective  cause  the  greatest  inconvenience  to  mice,  which 
suffer  obviously  from  great  pain,  and  have  to  be  quickly  de- 
stroyed. It  was  found,  however,  that  relatively  enormous  doses 
could  be  injected  directly  into  the  venous  system  and  tolerated 
without  any  visible  discomfort.  A  quantity  of  fluid  almost 
equal  to  the  total  amount  of  blood  in  a  mouse  can  be  so  in- 
jected, and,  weight  for  weight  of  animal,  doses  of  trypsin  .300 
times  greater  than  those  advised  for  administration  to  the 
human  subject  have  been  introduced  into  the  circulation  within 
a  short  space  of  time.  The  negative  results  on  the  growth  of 
tumours  bore  out  those  obtained  with  subcutaneous  injection. 


THE   INVESTIGATION   OF    "CANCER   CURES"     245 

''The  effect  on  tumour  growth  was  tested  in  yet  a  third  way. 
Mice  were  treated  by  the  direct  introduction  of  trypsin  into 
the  circulation  before  inoculation  with  a  transplantable  tumour, 
and  the  treatment  continued  during  the  succeeding  ten  days 
following  inoculation,  i.  e.,  till  that  time  had  elapsed  within 
which  the  new  tumours  usually  develop.  The  treatment  was 
powerless  to  prevent  the  inoculated  tumour  tissue  from  'taking.' 
The  results  were  found  to  be  quite  independent  of  the  amount 
of  trypsin  injected.  The  fact  that  the  newly  implanted  tissue 
established  itself,  disposes  of  the  hypothetical  objection  that 
the  other  methods  of  testing  trypsin  had  failed  because  the 
tumour  cells  had  in  course  of  treatment  been  able  to  immunize 
themselves  against  trypsin.  The  subsequent  growth  of  the 
tumours  in  the  mice  which  had  been  previously  treated  and  con- 
tinued to  be  treated  with  trypsin  showed  no  differences  from 
that  of  the  tumours  in  normal  animals  not  treated  by  trypsin." 

The  method  seemed  to  offer  an  unusually  hopeful  field  for 
legitimate  clinical  experimentation.  The  originator  of  the 
theory  upon  which  it  was  based,  Dr.  John  Beard,  of  the  Depart- 
ment of  Embryology,  University  of  Edinburgh,  brought  to  the 
work  a  scientific  spirit,  a  mind  trained  in  the  verification  of 
hypotheses  in  his  own  work,  and  a  reputation  for  earnestness 
and  sincerity  of  purpose  which  at  once  inspired  confidence. 
Not  being  a  doctor  of  medicine,  he  had  no  means  at  his  disposal 
for  testing  his  theories,  and  hence  he  appealed  to  the  medical 
profession  that  such  a  test  be  made  as  would  prove  or  disprove 
the  correctness  of  his  hypotheses. 

Dr.  Beard  succeeded  in  arousing  the  interest  of  a  goodly 
number  of  members  of  the  medical  profession,  both  in  Europe 
and  in  America,  as  was  shown  by  the  fact  that  more  than  one 
hundred  articles  had  appeared  concerning  the  matter  up  to  the 
time  we  began  our  test,  and  that  five  hundred  physicians, 
out  of  more  than  three  thousand  to  whom  letters  of  inquiry 
were  sent  by  me  as  Secretary  of  the  Department  of  Scientific 
Research  of  the  ISTew  York  Skin  and  Cancer  Hospital,  had  em- 
ployed the  method  in  one  or  more  cases. 

There  seemed  quite  enough  of  possible  value  in  the  treatment 
to'  warrant  its  trial.  Furthermore,  through  the  overzealous 
influence  of  certain  medical  writers  for  the  lay  press,  and  of  a 
few  premature  enthusiasts  within  the  ranks  of  the  profession  it- 
self, the  method  was  heralded  far  and  wide,  and  patients  them- 
selves soon  began  to  make  the  demand  that  it  be  tried  in  their 
cases,  attesting  their  willingness  to  abide  by  the  consequences. 

Hoping  that  it  might  prove  at  least  a  hopeful  adjuvant,  if 
not  the  boon  which  had  been  predicted,  and  believing  that  it 


246  THE   CANCER   PROBLEM 

would  do  no  barm,  we  proceeded  with  the  test  in  more  than 
one  hundred  cases,  one  hundred  of  which  are  included  in  the 
appended  table  in  the  re])ort. 

The  hospital  furnished  a  sufficiently  large  number  of  pa- 
tients from  which  to  draw  the  major  proportion  of  the  cases  in 
which  the  treatment  was  employed.  To  use  it  only  in  advanced, 
irremovable,  and  inoperable  cases  was,  perhaps,  simple  enough; 
but  such  3ases  do  not  give  a  sufficient  basis  for  a  complete  trial. 
The  surgeon,  who  must  look  upon  the  matter,  not  as  a  ''pure 
scientist"  (quoting  a  term  applied  by  Dr.  Beard  to  himself), 
cannot  bring  himself  voluntarily  to  subject  a  patient  with  can- 
cer in  an  early  stage,  when  the  disease  is  amenable  to  complete 
removal  (and  probable  cure)  by  surgical  intervention,  to  ex- 
perimentation wdth  any  non-surgical  agent,  no  matter  upon 
what  scientific  basis  it  may  be  exploited.  Of  course,  in  the 
judgment  of  some,  certain  superficial  local  growths  form  legiti- 
mate exceptions  to  this  general  statement.  Such  a  method, 
therefore,  may  be  tried  in  early  cases  only  where,  despite  the 
surgeon's  earnest  advice,  operation  is  positively  refused  by  the 
patient,  or  where,  for  reasons  aside  from  the  cancer,  it  is  im- 
possible to  operate.  Twenty-eight  of  the  one  hundred  cases 
treated  in  the  course  of  the  three-year  test  of  the  enzjTne 
method  were  of  this  character.  The  majority,  however,  were 
in  various  advanced  stages  of  the  disease. 

An  enormous  amount  of  time  and  patience,  and  a  goodly  sum 
of  money,  were  necessary  in  following  out  the  details  of  the 
test.  Inasmuch  as  the  trial,  of  necessity,  extended  over  a 
long  period  of  time,  in  some  cases  months,  it  was  not  prac- 
ticable in  every  instance  to  care  for  the  patient  in  the  hospital, 
the  individuals  themselves  not  infrequently  objecting  to  being 
so  long  away  from  home.  Under  these  circumstances,  when  the 
patient  could  not  afford  the  expense,  it  was  necessary  for  us  to 
furnish  medical  attention  and  to  employ  trained  nurses  to  ad- 
minister the  treatment  and  to  carry  out  the  regime  in  the  home 
after  the  patient's  discharge  from  the  hospital.  To  follow  up 
the  records  in  all  cases,  from  week  to  week  and  from  month  to 
month,  in  such  manner  as  to  render  possible  an  accurate  report 
of  each,  in  many  instances  necessitated  tracing  the  patient  from 
tenement  to  tenement^  sometimes  from  city  to  city.  Innu- 
merable obstacles  were  confronted  at  every  turn.  We  en- 
deavored, however,  to  meet  them  as  they  arose,  to  follow  the 
regime  outlined  as  closely  as  possible  in  accordance  with  the 
exigencies  of  each  individual  case,  and  to  keep  as  accurate 
data  as  possible  in  each  instance. 

In  addition  to  the  use  of  the  enzymes,  many  details  of  man- 


THE   INVESTIGATION   OF   "CANCER   CURES"     247 

agement  were  urged  by  Dr.  Beard.  His  various  suggestions 
were  executed,  and  the  treatment  was  carried  on  with  his  knowl- 
edge and  approval  throughout.^  Furthermore,  in  a  certain 
number  of  cases  a  careful  study  was  made  of  the  blood  and 
urine,  and  microscopical  and  gross  specimens  were  sent  to  many 
pathologists  of  repute,  particularly  where  there  was  any  doubt 
as  to  the  diagnosis  of  malignancy. 

The  materials  employed,  for  which  we  were  indebted  to  Mr. 
B.  T.  Fairchild,  who  cooperated  with  Dr.  Beard,  were  as  fol- 
lows: (1)  Holadin  capsule,  a  pancreas  gland  extract  contain- 
ing all  the  pancreas  enzymes — trypsin,  amylopsin,  and  lipase — 
and  the  milk-curdling  ferments.  This  was  given  to  aid  diges- 
tion. (2)  "Pepule"  oxgall  compound,  which  contains  inspis- 
sated oxgall,  extractum  pancreatis,  and  extract  of  nux  vomica. 
The  object  of  this  was  to  give  tone  to  the  bowel  and  to  aid 
elimination.  (3)  Lotio  pancreatis,  a  glycerin  extract  prepared 
directly  from  the  fresh  gland  and  carrying  in  solution  the  en- 
tire soluble  gland  constituents.  This  solvent  of  broken-down 
tissue  was  applied  topically  to  the  ulcerating  surfaces.  (4) 
Injectio  trypsini,  a  glycerin  extract  of  trypsin  which,  according 
to  Beard,  was  supposed  to  *'kill"  the  cancer  cells.  (5)  Injectio 
amylopsini,  a  glycerin  extract  of  amylopsin,  which  was  thought 
to  "digest"  the  dead  cancer  cells. 

The  first  pancreas  injections  were  made  of  a  proteolytic 
power  equal  to  two  per  cent,  of  trypsin,  and  had  been  adopted 
in  consequence  of  a  strength  or  "percentage"  of  trypsin,  first 
extemporaneously  prepared  and  used  by  Beard  and  others. 
The  medium,  60  per  cent,  glycerin,  had  already  been  found  to 
meet  the  requirements,  containing  the  enzymes  of  the  fresh 
pancreas  extract  in  an  active  and  sterile  condition.  This, 
however,  necessitated  preliminary  dilution  in  making  the  in- 
jection ready  for  use.  Experience  warranted  an  increase  in 
tryptic  power,  and  it  was  found  that  this  desideratum  could  be 
achieved  only  by  a  more  aqueous  medium.  Accordingly,  the  pro- 
portion of  glycerin  was  reduced  to  20  per  cent.  This  lower  con- 
tent of  glycerin  afforded  the  advantage  of  increase  of  trypsin 
content  and  increase  of  dosage,  as  found  in  the  ampoule. 

The  various  injections  of  trypsin  furnished  for  our  use  were 
identified  for  convenience  of  record  as  follows:  "Regular," 
60  per  cent,  glycerin,  equal  to  2  per  cent,  trypsin  (dry)  ;  "For- 
tified," 60  per  cent,  glycerin,  double  strength  of  the  "Regular"; 

1  Dr.  Beard  {op.  cit.,  pp.  180-181)  says  he  was  "entirely  ignorant  of 
his  (the  author's)  doings,"  with  the  exception  of  one  of  the  earlier  cases. 
My  personal  visits  to  his  home,  my  numerous  written  communications  from 
him,  all  of  which  are  on  file,  and  the  history  card  of  a  patient  referred  to 
me  by  him,  show  that  Dr.  Beard's  memory  is  at  fault  in  this  matter. 


248  THE   CANCER    PROBLEM 

'"Special,"  20  per  cent,  glycerin,  double  the  strength  of  the 
"Eegular" ;  ''Special  XX,"  20  per  cent,  glycerin,  four  times 
the  strength  of  the  "Regular"  (this  was  used  in  most  of  our 
cases)  ;  "Special  Quadruple  X,"  20  per  cent,  glycerin,  six  times 
the  strength  of  the  "Regular"  (prepared  especially  for  this  test, 
and  said  at  the  time  to  be  the  strongest  it  was  possibk'  to  make). 

Injections  of  amylopsin  of  corresponding  strength  were 
furnished.  The  20  per  cent,  glycerin  amylopsin  injection  pre- 
sented parallel  advantages  with  the  20  per  cent,  trypsin  injec- 
tion, in  increased  potency,  and  in  available  volume  of  dosage 
without  dilution.  Thus  twenty  minims  of  the  20  per  cent, 
glycerin  ''Special"  carried  an  enzyme  potency  corresponding  to 
a  sixty-minim  injection  composed  of  twenty  minims  of  60  per 
cent,  glycerin  solution  from  an  ampoule,  with  forty  minims 
diluent — sterilized  water. 

Having  noted  the  strength  of  the  injections,  it  will  be  seen 
from  the  cases  detailed  later,  how  much  stronger  were  the  in- 
jections used  in  many  of  our  tests  than  were  those  employed 
in  the  cases  reported  iDy  a  number  of  writers  during  the  earlier 
months  of  the  history  of  this  method.  The  idea  entertained  by 
many  at  first,  to  the  effect  that  only  moderate  doses  of  weak 
solutions  of  trypsin  could  be  tolerated,  was  proved  entirely 
erroneous  in  our  experience.  In  many  cases  we  were  able  to 
give  daily  two  or  three  ampoules  (twenty  minims  each),  and  in 
several  instances,  one  hundred  minims  of  the  "Quadruple  X" 
solutions  were  given  for  days  at  a  time  with  no  untoward  ef- 
fects. 

From  the  above  it  will  be  seen  how  absurd  were  some  of  the 
earlier  claims  of  "cures,"  as  well  as  some  of  the  reports  of 
unusual  symptoms  and  "terrific"  results  noted  from  the  small 
doses  employed. 

From  this  trial  the  following  conclusions  were  drawn: 

(1)  That  the  internal  medication  with  holadin  and  oxgall 
aided  digestion  and  increased  elimination. 

(2)  That  lotio  pancreatis  applied  locally  cleaned  the  ulcer- 
ating surface  by  removing  organisms,  thus  aiding  in  diminish- 
ing the  absorption  of  their  products. 

(3)  That  aiding  digestion,  increasing  elimination  (by  skin, 
kidneys,  and  bowels),  and  increasing  local  absorption,  were  the 
most  important  features  of  the  treatment. 

(4)  That  the  regime,  by  increasing  resistance,  seemed,  in 
some  cases,  to  decrease  the  rapidity  of  the  malignant  process. 

(5)  That  control  cases  given  injections  of  glycerin  and 
water,  or  sterile  water  alone,  plus  the  regime,  fared  as  well  as 
did  those  on  the  full  enzyme  treatment. 


THE   INVESTIGATION   OF   "CANCER   CURES"     249 

(6)  That  injectio  trypsini,  in  some  cases,  seemed  to  cause 
more  rapid  disintegration  of  cancerous  tissue — to  "liquefy"  it, 
according  to  Beard. 

(7)  That,  while  it  seemed  to  accelerate  the  breaking  down 
in  the  center  of  the  tumor  mass,  the  periphery  was  found  to  be 
actively  guwing,  as  was  true  of  Case  VII  (Case  I,  of  Dr.  W. 
J.  Morton's  published  series).  When  injected  into  the  tumor 
itself  this  disintegration  was  more  marked. 

(8)  That  because  of  the  tendency  of  the  injectio  trypsini 
to  disintegrate  the  tissues,  it  may  be  a  direct  menace  to  life 
(a)  by  eroding  large  blood  vessels  (when  the  disease  is  con- 
tiguous to  these  structures,  as  when  deep  in  the  neck  or  in  the 
pelvis),  thus  causing  death  from  hemorrhage;  (b)  when  given 
in  large  doses,  over  considerable  periods  of  time,  by  overwhelm- 
ing the  system  with  toxic  products  (tumor  toxins),  thus,  in 
some  cases,  hastening  death. 

(9)  That  the  injections  were  often  painful,  and  patients 
many  times  refused  to  take  them. 

(10)  That  the  so-called  "trypsin  abscess"  proved,  upon  ex- 
amination of  the  material,  to  be  unabsorbed  injectio  trypsini 
plus  broken-down  tissue. 

(11)  That  when  real  abscesses  formed  they  were  due  to 
faulty  technic,  to  localization  of  a  general  sepsis  resulting  from 
the  absorption  of  toxic  products,  to  an  accompanying  sepsis  of 
whatever  origin,  or  to  a  complicating  acute  infection. 

(12)  That  injectio  amylopsini  seems  to  diminish  cachexia 
in  some  cases,  in  accordance  with  the  claims  of  Beard  and 
others. 

(13)  That  in  some  cases  there  was  no  reason  to  believe 
that  injection  amylopsini  exerted  the  action  claimed  for  it. 

(14)  That  when  amylopsin  was  injected  directly  into  the 
indurated  area  left  after  injecting  trypsin,  absorption  of  the 
trypsin  solution  was  not  hastened. 

(15)  That  100  minims  daily  of  the  "Quadruple  X"  solu- 
tion, the  strongest  made,  was  given  in  some  cases  with  no 
untoward  effects. 

(16)  That  improvement  in  hemoglobin  (5  to  12  per  cent.) 
during  the  first  few  weeks  of  trypsin  treatment,  occurred  in 
about  one-sixth  of  the  cases  examined.  In  only  one-third  of 
these  was  the  increase  ascribable  to  the  trypsin  alone. 

(17)  That  in  a  few  of  the  cases  a  gradual  and  moderate 
increase  in  the  number  of  polymorphonuclear  neutrophile  cells 
was  noted  during  the  first  two  weeks  of  the  trypsin  treatment. 

(18)  That,  with  the  exception  of  two  cases,  such  leuko- 
cytosis  as   was   noted  was   attributable   to   the   occurrence   of 


250  THE   CANCER   PROBLEM 

complications    during    the    first    two    weeks    of    trypsin    treat- 
ment. 

(lO)  Tliat  in  fifteen  ont  of  twenty-two  cases  above  men- 
tioned, a  steady  increase  (6  to  12  per  cent.)  in  number  of 
eosinophile  cells  was  noted  while  patients  were  on  the  trypsin 
injections.  There  was  no  eosinophilia  in  the  control  cases,  nor 
in  the  cases  treated  bv  trypsin  given  by  mouth. 

(20)  That  eosinophilia  occurred  regularly  in  cases  of  car- 
cinoma involving  the  bones  or  the  intestines,  even  without  the 
exhibition  of  trypsin. 

(21)  That  the  claims  for  eosinophilia  as  a  test  have  not 
been  substantiated  in  our  experience. 

(22)  That  in  two  cases  albumin  and  casts  were  found  in 
the  urine  before  treatment  was  begTin.  In  neither  of  these  was 
the  amount  of  albumin  or  the  number  of  casts  increased  at  any 
time  throughout  the  continuation  of  the  trypsin  injections. 

(23)  That  in  severe  cases  in  the  very  last  stages  of  the 
disease,  hyaline,  granular,  a  few  pus  casts,  and  occasionally  al- 
bumin made  their  appearance. 

(24)  That  in  two  other  cases  in  which  it  was  impossible 
to  obtain  specimens  of  urine  before  beginning  the  treatment, 
albumin  and  casts  were  present  when  the  cases  came  under 
examination;  and  as  the  trypsin  doses  were  increased  the 
amount  of  albumin  and  the  number  of  casts  were  increased. 

(25)  That  dextrose  was  at  no  time  found  in  any  of  the 
urine  specimens  examined,  not  even  when  untoward  manifes- 
tations of  trypsin  were  present  and  large  doses  of  amylopsin 
were  being  given. 

(26)  That  the  series  of  experiments  which  were  conducted 
for  the  purpose  of  ascertaining  the  presence  or  absence  of  an 
enzyme  in  the  urine,  with  properties  of  digestion  similar  to 
trypsin,  showed  the  presence  of  such  an  enzyme  body  (irregu- 
larly present)  in  (a)  trypsin-treated  cancer  cases;  (b)  non- 
cancerous untreated  cases;  (c)  cancer  cases  which  had  not 
received  the  trypsin  treatment. 

(27)  That  the  exact  potency  of  this  enzyme  body  in  the 
urine  with  reference  to  the  treatment  was  not  ascertained.  No 
enz^ane  body  was  found  in  urines  in  which  there  was  ammonia- 
cal  decomposition. 

(28)  That  the  enz^Tne  treatment  as  administered  in  the 
cases  herewith  reported,  and  according  to  the  suggestions  of 
Dr.  Beard,  plus  important  details  of  regime,  does  not  check 
the  cancerous  process. 

(29)  That  it  does  not  prevent  metastasis. 

(30)  That  it  does  not  cure  cancer. 


THE   INVESTIGATION   OF   "CANCER   CURES"     25] 

The  test  was  a  negative  one,  unfortunately,  but  it  sliould 
serve  the  purpose,  with  both  the  medical  profession  and  the 
public,  of  illustrating  the  thorough,  exhaustive,  scientific  tests 
to  which  reasonable  measures  are  subjected  in  the  effort  to 
find  non-surgical  methods  of  treating  cancer. 

Other  hospitals  and  research  centers  have  been  equally  will- 
ing to  give  a  fair  trial  to  any  method  which  has  answered  sci- 
entific requirements,  even  to  a  partial  degree.  Rotable  in- 
stances of  this  are  the  Imperial  Cancer  Research  Fund;  the 
Middlesex  and  Cancer  Hospitals,  London ;  the  Cancer  Hos- 
pital, Heidelberg,  and  the  Cancer  Pavilion  of  the  Charite, 
Berlin. 

In  the  pages  which  follow  are  recorded  illustrations  of  "fair 
tests"  applied  to  other  measures  which  from  time  to  time  have 
been  proposed  for  the  treatment  of  cancer. 


SERUM    FROM    BIRDS    OF    PREY 

In  1904,  two  accredited  physicians,  with  European  training, 
presenting  letters  of  introduction  from  the  Commissioner  of 
Public  Health  of  ISTew  York  City,  and  from  well-known  phy- 
sicians, requested  the  writer  to  test  a  serum  which  they  claimed 
to  be  a  cure  for  cancer.  The  serum  was  made  from  birds  of 
prey  to  which  cancer  tissue  and  cancer  juice  had  been  fed  for 
months,  which  had  then  been  killed,  and  from  which  the  blood 
serum  had  been  obtained.  This  was  injected  into  the  sub- 
cutaneous tissues  of  the  subject  being  treated,  not  into  the 
cancer  area. 

After  duly  weighing  the  evidence  presented,  it  was  decided 
to  test  the  agent.  This  was  done  systematically,  according 
to  the  suggestions  of  the  originators,  in  some  fifteen  cases. 
The  serum  was  applied  by  the  doctors,  who  had  taken  a  small 
place  in  the  country  where  they  kept  the  birds  from  which 
the  serum  was  obtained. 

There  were  periods  of  apparent  improvement,  lessening  of 
pain  and  other  symptoms,  but  it  was  soon  realized  that  these 
remissions  of  symptoms  were  nothing  more  than  could  be 
accounted  for  by  the  psychic  effect  of  the  new  hope  which  a 
new  remedy  always  inspires  for  a  time.  After  satisfying  our- 
selves fully  that  this  was  true,  and  seeing  no  real  benefit  in 
a  single  case,  the  treatment  was  abandoned.  So  far  as  I  am 
aware  nothing  has  ever  been  accomplished  by  means  of  this 
serum. 


252  THE   CANCER   PROBLEM 

"CANCROIDIN,"    "ANTIMERISTEM" 

(The   Otto  Schmidt  Serum  or  "Vaccine) 

The  Schmidt  serum  or  vaccine  affords  au  excellent  illustra- 
tion of  the  willingness  of  individual  physicians,  cancer  hos- 
pitals, and  research  institutions  to  test  a  proposed  new  method 
of  treatment  which  has  a  seeming  foundation  in  scientific 
theory  or  principle. 

The  Schmidt  ''cure,"  like  a  number  of  apparently  scientific 
methods,  was  based  upon  the  supposed  discovery  of  the  cause 
of  cancer.  Schmidt  claimed  to  have  isolated  and  cultivated  a 
cancer  parasite,  from  which  the  proposed  serum  was  prepared 
by  two  methods. 

By  the  first  method,  cultures  were  made  of  the  parasite, 
these  were  sterilized,  and  from  them  a  pure  "killed  culture" 
was  obtained.  This  was  injected  subcutaneously  in  small  but 
increasing  doses. 

According  to  the  second  method,  an  animal  was  inoculated 
with  increasing  doses  of  the  "cancer  parasite,"  and  from  the 
animal  a  serum  was  obtained.  This  was  injected  subcutane- 
ously into  the  subject  to  be  treated. 

The  method  was  first  announced  to  the  English  medical 
world  in  a  paper  read  by  Dr.  Josse  Johnson  before  the  Aber- 
nethian  Society  of  St.  Bartholomew's  Hospital  (a  students' 
medical  society),  November  5,  1905.  Dr.  Johnson  made  for 
Dr.  Schmidt,  the  announcement  of  the  discovery  of  the  para- 
site, of  the  preparation  of  the  "killed  culture"  and  the  serum, 
and  of  the  successful  treatment  of  twenty-nine  cases. 

Despite  the  fact  that  the  proposed  "cure"  had  been  an- 
nounced with  a  decided  suggestion  of  secrecy,  the  Middlesex 
Hospital,  London,  under  the  direction  of  J.  W.  Glenton  Myler, 
Registrar  to  the  Cancer  Wing,^  decided  to  investigate  the 
method,  both  as  to  its  curative  properties  and  its  diagnostic 
value. 

IsTine  patients  in  the  cancer  wards  of  the  hospital,  with  their 
consent,  were  subjected  to  the  treatment,  the  selection  of  suit- 
able cases  having  been  made  by  Dr.  Johnson  and  the  hospital 
medical  officers.  Dr.  Schmidt  visited  the  hospital  during  the 
test  and  expressed  himself  as  being  satisfied  with  the  cases. 

In  every  detail  the  test  was  conducted  with  perfect  fairness 
to  the  originator  of  the  method.  Photographic  and  other 
records  of  the  cases  were  carefully  kept,  and  the  treatment 

1  Archives  of  the  Middlesex  Hospital,  Vol.  Ill,  Third  Report  from  the 
Cancer  Eeseareh  Laboratories. 


THE   INVESTIGATION   OF   "CANCER   CURES"     253 

was  administered  in  accordance  with  Dr.  Schmidt's  directions, 
the  injections  throughout  being  made  by  his  friend  and  cham- 
pion, Dr.  Johnson. 

Instead  of  proving  to  be  a  cure,  the  method  was  of  no  benefit 
in  any  case.  Its  diagnostic  vahie  was  nil^  no  case  of  undoubted 
cancer  showing  the  slightest  temperature  reaction,  as  it  was 
claimed  would  be  the  case.  The  most  that  could  be  said  of 
the  treatment  in  the  Middlesex  report  was  that  it  at  least  did 
no  harm,  since  it  in  no  way  modified  the  course  of  the  disease. 

Despite  the  objections  and  protests  of  the  medical  profession 
of  Germany,  the  method  continued  for  a  time  to  receive  more 
or  less  notice  in  the  medical  and  secular  press. 

Later  "Cancroidin"  appeared  in  print  under  the  name  "An- 
timeristem,"  and  numerous  reports  have  appeared  in  medical 
literature  relative  to  this  agent,  prepared  from  cultures  of 
Schmidt's  mucor  racemosus  malignus.  According  to  Jo- 
hannsen,*  aside  from  a  few  cases  reported  by  Schmidt  ^  him- 
self, practically  all  the  published  cases  concern  improvements, 
but  not  cures.  In  numerous  instances  in  which  the  method  was 
employed,  no  favorable  influence  was  reported.  Kolb,^  for 
example,  holds  that  Schmidt's  "Antimeristem"  exerts  no  spe- 
cific effect  of  any  kind  upon  the  tumor,  merely  giving  rise  to  a 
reaction  in  the  inflamed  vicinity. 

Aside  from  furnishing  an  excellent  illustration  of  the  wil- 
lingness of  the  medical  profession  and  of  research  institutions 
to  give  a  fair  trial  to  a  proposed  remedy  for  cancer,  the  vari- 
ously named  Schmidt  method  affords  an  illustrating  example 
of  the  commercial  aspect  of  many  of  the  alleged  "cures"  for 
this  disease.  The  following  advertisements,  of  recent  appear- 
ance, translated  verbatim,  need  no  comment: 

"VACCINE-THERAPY* 

''For  Malignant  Tumors 

"The  great  efficacy  of  the  Vaccine  Antimerist em- Schmidt  in  car- 
cinoma and  sarcoma  is  shown  by  hundreds  of  reports,  from  university 
clinics,  large  hospitals,  and  medical  practitioners. 

"Indications :  In  obscure  cases,  for  the  confirmation  of  the  diagno- 
sis; after  radical  operations,  for  the  prevention  of  recurrence;   after 

1  Johannsen. — ' '  Ueber  drei  Verreuhe  der  Behandlung  inoperabler  Kar- 
zinome  mit  Antimeristem, "  Centralblatt  filr  Gyndlcologie,  1912,  Vol.  36, 
No.  14,  p.  426. 

2  Schmidt,  0. — '  *  Die  Wirkungsweire  des  Antimeristem  bei  der  Krebs- 
behandlung, "  Zeitschrift  filr  aerstliche  Fortbildung,  No.  21,  1911,  p.  649. 

3  Kolb,  K. — "Ein  Beitrag  zu  den  Misserfolzen  mit  Antimeristem  (Can- 
croidin-Schmidt),"   Munchener  med.    Woch.,   1911,   p.    1076. 

*  Advertisement  on  title  page  of  Ars  Medici,  January,  1912. 


254  THE   CANCER   PROBLEM 

partial  operations,  for  the  supploiuentiiig  of  the  result;  in  all  cases 
which  for  some  reason  are  inoperable  (primary  tumors,  recun-ences, 
and  metastases). 

''The  preparation  is  dispensed  only  on  professional  prescription. 

^'Directions  for  use,  in  German,  English,  French,  Italian,  Russian, 
Spanish,  Swedish,  and  Noi-wegian. 

^'Literature  in  several  languages  may.be  obtained  through  the  under- 
signed firm. 

"General  Deposits  in  all  countries. 

"Sole  Manufacturer:    Bacteriologico-Chemical  Laboratory, 

"WoLFANG  Schmidt, 

"Cologne,  Germany." 

"IN   DEFENSE   AND    FOR    INFORMATION  ^ 

"In  the  course  of  the  last  months  the  daily  papers  have  repeatedly 
published  articles  from  the  pens  of  experts,  dealing  with  the  problem 
of  the  present  status  of  cancer  treatment. 

"The  Present  Status  of  Cancer  Treatment 

"All  those  procedures  are  enumerated  therein  which  at  some  time, 
in  animal  experiments  or  clinical  cases,  have  shown  an  influence  upon 
the  cancer  tumors.  But  the  procedure  which  has  accomplished  by  far 
the  largest  number  of  cures,  and  moreover  in  the  most  malignant  and 
serious  cases,  in  contradistinction  from  other  measures, — this  proce- 
dure they  are  endeavoiing  to  hush. 

"To  Hush  Up 

"We  are  refemng  to  the  treatment  which  was  introduced  into  prac- 
tice and  perfected  into  a  system  by  Sanitatsrat  [Health-Councillor — 
an  official  title]  Dr.  0.  Schmidt,  of  Cologne,  being  a  treatment  with 
his  vaccine,  'Antimeristem,'  which  is  manufactured  by  the  undersigned. 
In  the  past  year,  Dr.  O.  Schmidt  was  enabled  to  report  40  cures  of 
cancer,  and  304  improvements,  in  part  approaching  to  a  cure.  At 
the  present  writing  these  figures  have  increased  by  13  cures  and  143 
improvements,  so  that  the  total  result  amounts  to  500  cases. 

"It  can  be  positively  assumed  that  about  the  same  number  of  cures 
and  improvements  have  not  been  published  in  medical  journals,  and 
have  not  come  to  the  knowledge  of  the  undersigned.  This  conclusion 
is  based  upon  the  fact  that  physicians,  in  i-eordering  the  preparation, 
frequently  mention  a  cure  which  they  obtained  in  previous  years. 

"Only  a  small  minority  of  the  patients  have  been  treated  by  Dr. 
Schmidt,  by  far  the  majority  having  been  under  the  treatment  of  other 
registered  physicians,  at  home  and  abroad.  It  seems  necessary  to 
make  special  mention  of  this  fact. 

"Among  those  who  have  reported  favorable  results  are  many  pro- 
fessoi-s  and  directors  of  university  clinics,  and  large  hospitals,  the 
principal  contingent  being  represented  by  general  practitioners.  The 
reports  of  these  representatives  of  medical  knowledge  have  either  not 
been  read,  or  are  intentionally  disregarded.  Would  any  one  dare  to 
declare  them  as  the  mental  products  of  incapable  persons,  or  as  vol- 
untary misstatements? 

"Dr.  Schmidt's  publication  of  last  year,  refen-ed  to  above,  is  con- 
cluded in  the  following  words:  *I  hope  that  at  last  there  will  be  an 
end  to  the  assertion,  made  by  the  competent  as  well  as  the  incompetent, 

1  Advertisement  in  Berliner   Vossisehe  Zeitung,  1913. 


THE   INVESTIGATION   OF   "CANCER   CURES"     255 

to  the  effect  that  as  yet  no  carcinoma  has  been  cured  by  Antimeristem; 
otherwise,  I  would  have  to  accuse  the  originator  of  a  similar  assertion 
as  being  guilty  of  an  advisedly  uttered  untruth.' 

"An  assertion  of  this  kind  has  not  been  propounded  since  that  time; 
for  there  are  other  means  by  which  they  hope  to  accomplish  their 
object,  namely  by  keeping  silence  and  hushing  up  the  facts  of  the  case. 

"It  is  far  from  the  intention  of  the  undersigned  to  proclaim  in  the 
daily  newspapers  the  value  of  Antimeristem,  which  moreover  is  only 
distributed  on  a  physician's  prescription.  But  he  demands  equal  rights 
for  all,  and,  as  this  principle  is  being  violated  over  and  over  again,  in  a 
matter  of  such  eminent  importance,  he  now  seeks  publicity. 

"BACTERIOLOGICO-CHEMICAL    LABORATORY, 

"WOLFANG  SCHMIDT_,  COLOGNE." 

The  important  aspects  of  these  advertisements  are  not  only 
their  direct  appeal  to  the  public,  and  the  usual  insimiation, 
openly  expressed,  that  the  alleged  remedy  is  being  wrongly 
boycotted  by  the  profession,  but  also  the  fact  that  they  were 
published  in  1913,  after  numerous  papers  had  shown  that  the 
treatment  was  valueless.  An  article  by  Jensen  -^  was  translated 
into  English,  and  apparently  was  still  being  spread  broadcast  in 
1913,  although  Dr.  Mamlock,  of  Berlin,  showed  ^  that  the  case 
therein  cited  could  not  be  used  to  support  Schmidt's  "Anti- 
meristem" treatment,  because  a  complication  with  syphilis  was 
almost  certainly  present.  This  possibility  was  also  admitted  by 
Jensen. 

Doubts  are  awakened  by  all  the  other  alleged  cures  of  which 
reports  have  been  accessible  to  the  author.  Two  cases  of  cancer 
of  the  tongue,  recorded  by  Aly,^  continued  to  grow  without  the 
slightest  sign  of  healing,  in  spite  of  Antimeristem  treatment, 
No  benefit  whatsoever  was  obtained  in  a  case  of  rectal  cancer 
shown  to  the  Medical  Society  of  Zwickaw  in  Saxony.  Profes- 
sor Kummel,  Director  of  the  Surgical  Klinik  in  Hamburg, 
proved  ^  that  a  case  claimed  as  a  cure  of  cancer  of  the  palate 
was  not  cancer  at  all.  Johannsen  obtained  absolutely  negative 
results  from  uterine  cancer.'^  An  exhaustive  investigation  of 
Schmidt's  claims  was  made  in  Czerny's  Institute  in  Heidel- 
berg by  Werner,^  who  recorded  uniformly  unfavorable  results. 
Editorial  comments  directed  against  the  use  of  Antimeristem 
and  its  advertisements  appear  in  the  same  leading  German 
medical  journal.'^ 

1  Jensen. — Deut.  med.  Woch. 

-  Mamlock. — Zeitschr.  f.   drziliche   Fortbildung,   No.   22,   1911. 

^Alj.—Deut.  med.  Woch.,  1910,  p.  1885. 

4  Kummel. — Deut.  med.  Woch.,  1912,  p.  1607. 

5  Johannsen. — Deut.  med.  Woch.,  1912,  p.  819. 

6  Werner. — Deut.   med.    Woch.,   1912,   p.   826. 

T  Deut.  med.  Woch.,  1912,  p.   1295,  and   1913,  p.  951. 


256  THE   CANCER   PROBLEM 

It  is  evident  that  "^Antimeristem"  has  been  tried,  and  tried 
fairly.  The  effrontery  with  which  it  is  still  advocated  and 
advertised  to-day  is  sufficient  evidence  of  the  confidence  with 
which  the  suffering  and  the  weak  are  appealed  to  and  urged 
to  undergo  a  course  of  useless,  if  not  harmful,  treatment,  with 
an  agent  which  costs  something  like  four  hundred  dollars,  or 
eighty  pounds,  according  to  the  pamphlets  and  circulars  issued 
by  the  vendors. 

DOYEN'S    SERUM 

Another  of  the  seemingly  scientific  "cures"  for  cancer  which 
has  been  subjected  to  the  crucial  test  of  scientific  investigation 
is  Doyen's  serum,  so  widely  heralded  a  few  years  ago,  and 
still  put  forward  to-day. 

In  1886  Doyen  presented  before  the  Academy  of  Science  at 
Paris  his  first  report  of  his  observations  concerning  the  pres- 
ence in  malignant  and  non-malignant  growths  of  small,  spher- 
oidal, mobile  bodies  which  he  thought  to  be  micro-organisms. 
In  1901  he  corroborated  these  observations  in  a  report  to  the 
Academy  of  Medicine  in  Paris.  In  1903,  before  the  Surgical 
Congress  of  Berlin,  he  further  substantiated  his  previous  re- 
ports, and  made  the  additional  claim  of  having  isolated  a 
micro-organism  from  both  malignant  and  non-malignant  tu- 
mors. He  gave  to  this  organism  the  name  Micrococcus  neo- 
formans,  and  claimed  that,  inoculated  into  animals,  it  had 
given  rise  to  neoplastic  formations. 

Doyen  believed  infection  of  the  body  with  this  Micrococcus 
neoformans  to  be  the  cause  of  the  development  of  new  groveths, 
such  infection  being  comparable  to  that  of  tuberculosis  and 
actinomycosis. 

The  outcome  of  this  claim  was  the  preparation  of  an  anti-can- 
cerous vaccine,  made  by  attenuating  and  increasing  the  viru- 
lence of  the  organism,  and  of  an  antitoxic  serum,  made  from 
the  horse  by  means  of  the  toxins  of  the  Micrococcus  neoformans. 

These  agents,  in  combination  with  surgical  procedure,  were 
employed  successfully,  according  to  Doyen,  in  21  out  of  126 
cases  of  malignant  and  non-malignant  growths  which  he  re- 
ported, in  1904,  before  the  Academy  of  Science  in  Paris.  The 
next  year  he  detailed  ^  42  "cures"  out  of  116  additional  cases. 

Naturally  this  "discovery"  was  immediately  heralded  all 
over  the  civilized  world,  the  secular  and  medical  press  devoted 
a  great  deal  of  attention  to  it,  and  many  cancer  patients  de- 
manded its  trial. 

1  Doyen. — "Etiologie  et  Traitement  du  Cancer,"  Paris,  1905. 


THE   INVESTIGATION   OF   "CANCER   CURES"      257 

While  interest  in  the  method  was  at  its  height  (which,  it 
may  be  recalled,  was  coincidental  with  the  height  of  the  inter- 
est in  the  parasitic  theory  of  the  cause  of  cancer),  the  authori- 
ties of  the  Brompton  Cancer  Hospital,  London,  requested  that 
inquiry  be  made  into  the  treatment  of  cancer  by  means  of  this 
serum.  Accordingly,  Dr.  Alexander  Paine  and  Dr.  David  J. 
Morgan  were  appointed  to  make  the  investigation  and  to  study 
the  presence  of  the  Micrococcus  neoformans  in  malignant  and 
non-malignant  growths. 

The  results  of  the  investigation  were  presented  before  the 
Royal  Medical  and  Chirurgical  Society  of  London,  March  27, 
1906.1 

Doyen  supplied  the  hospital  with  vaccine  and  serum,  with 
which  9  cases  of  malignant  disease  were  treated,  most  of  the 
cases  having  been  seen  by  him  and  pronounced  suitable  for  the 
method.  In  each  instance  his  serum  was  used  alone,  that  is, 
without  surgical  or  other  treatment,  in  order  that  the  effect  of 
the  agents  might  not  be  obscured. 

The  method  consisted  in  the  injection,  deep  into  the  muscles 
of  the  buttock,  at  stated  intervals  of  time,  of  10  c.  c.  of  the 
serum  or  vaccine.  In  2  of  the  9  cases  there  was  no  local  change 
in  the  growth.  In  the  remaining  7  there  was  no  constitutional 
reaction,  in  2  there  was  marked  increase  of  pain,  and  in  the 
remaining  3,  cardiac  failure,  with  collapse  in  2  cases.  No  ben- 
efit was  noted  in  any  case  further  than  the  temporary  relief  of 
pain,  which,  as  is  well  known,  varies  considerably  under  any 
circumstances. 

The  investigation  as  to  the  presence  of  the  Micrococcus  neo- 
formans is  discussed  under  Etiology,  Section  IV,  Chapter  1. 

CHIAN    TURPENTINE 

(Pistacia  Terebenthus) 

Chian  Turpentine,  given  internally,  and  by  injection,  fur- 
nishes an  excellent  illustration  of  the  recurring  use  of  a  given 
agent  in  the  treatment  of  cancer.  It  was  first  used,  apparently, 
by  Clay,^  of  Birmingham,  England.  Immediately  following 
his  favorable  report,  it  was  tried  during  a  number  of  months 
by  Hulke  ^  at  the  Middlesex  Hospital,  and  an  unfavorable  re- 

1  Trans,  of  the  Eoyal  Medical  and  Chirurgical  Society,  London,  1906, 
Vol.  LXXXIX,  p.  707. 

2  Clay,  J.— "On  the  Treatment  of  Cancer,"  1882,  See  also:  Lancet, 
1880-1887. 

3  Hulke,  J.  W. — ' '  Memorandum  on  the  Eesults  of  a  Trial  of  Chian  Tur- 
pentine as  a  Eeputed  Remedy  for  Cancer  of  the  Female  Genital  Organs, 
made  during  several  months  in  the  year  1880,  in  Whitbread  Ward,  Middle- 
sex Hospital,"  Lancet,  London,  1881,  I,  p.  1019. 


258  THE   CANCER    PROBLEM 

port  rendered.  Despite  this  discrepancy  in  the  findings,  it  has 
continued  to  be  used  from  time  to  time,  until  within  the  last 
few  years,  when  it  seems  to  have  been  finally  abandoned.  Judg- 
ing from  other  instances,  however,  it  is  apt  to  appear  in  the 
archives  of  cancer  literature  at  any  time. 

Clay  gave  it  internally,  and  claimed  great  success  from  its 
use.  Ilulke  said  of  his  experience:  ''The  result  of  this  trial 
completely  demonstrated  to  my  own  mind  that  Chian  Turpen- 
tiue  is  thoroughly  useless  as  a  remedy  for  cancer,  whether  of  the 
female  generative  organs  or  of  other  parts.  It  was  adminis- 
tered during  several  months  to  several  suffering  from  uterine 
cancer,  which,  in  spite  of  it,  continued  its  fatal  course.  In  not 
one  case  did  the  vaginal  discharge  assume  the  thick,  ropy  char- 
acter mentioned  by  Prof.  Clay.  As  a  reputed  anodyne  it  failed 
to  lull  pain,  and  during  its  use  opium  was  found  indispensable. 
With  respect  to  its  alleged  hemostatic  powers,  hemorrhage 
occurred  as  frequently  and  as  copiously  in  women  taking  the 
turpentine  as  in  others  to  whom  it  was  not  given." 

Despite  this  unfavorable  report  it  was  again  used  in  the 
Middlesex  Hospital  many  years  later. ^  A  patient  with  car- 
cinoma of  the  cervix  took  it,  in  dessertspoonful  doses,  three 
times  a  day,  regularly  every  day  for  nine  months,  during  which 
time  the  disease  steadily  progressed. 

Shaw-Mackenzie  ^  first  used  Chian  Turpentine  internally 
in  1891,  but  later  began  to  employ  it  hypodermatically,  claim- 
ing good  results. 

From  the  sum  total  of  evidence  it  may  be  justly  concluded 
that  Chian  Turpentine  offers  no  hope  of  cure,  and  little  if 
any  benefit  as  a  palliative  measure. 


SODIUM   OLEATE    (Soap  Solution)    AND  OX-GAIL 

John  Holden  Webb,^  of  Melbourne,  Australia,  claims  to 
have  cured  cancer  by  means  of  injections  internally  of  cholea- 
terin  in  soap  solution  and  ox-gall  ("animal  gum").  The  theory 
upon  which  this  practice  is  based  is  as  follows:  "Cancer  is 
uncontrolled  cell  proliferation  due  to  the  deposition  of  choles- 
terin,  from  the  cell,  either  locally,  from  injury,  or  dependent 
on  some  chemical  change  in  the  liver  secretion,  associated  with 
deficiency  of  the  bile-salts  which  normally  hold  cholesterin  in 
solution."      Webb   found    that   salt   solution   offered   the   best 

1  Myler,    Glenton. — Archives   of   the   Middlesex   Hospital,    1904,    Vol.    II, 
p.  65. 

2  ShavT-Mackenzie. — ' '  The  Nature  and  Treatment  of  Cancer, ' '  1905. 

3  Webb,  John  Holden.— Lancet,  October  12,   1901,  p.  976. 


THE   INVESTIGATION   OF   "CANCER   CURES"      259 

medium  for  the  cliolesterin  injections.  After  some  disappoint- 
ment with  the  method,  Webb  omitted  the  cholesterin  and  used 
merely  injections  of  superfatted  soap  in  conjunction  with  the 
internal  administration  of  ox-gall. 

Shaw-Mackenzie  ^  reported  some  successes  with  this  method; 
and  from  time  to  time  other  more  or  less  desultory  reports  of 
its  use  have  appeared  in  medical  literature.  JSFone  of  these, 
however,  has  been  sufficiently  definite  and  convincing  to  giv€ 
it  a  permanent  place  in  the  medical  treatment  of  cancer.  Per- 
sonal correspondence  with  Dr.  Webb  failed  to  give  me  enough 
evidence  of  the  usefulness  of  the  method  to  warrant  its  trial. 
Eecent  instances  of  its  use  have  come  to  my  notice,  however, 
and  without  doubt  history  will  repeat  itself  with  this  agent. 


MOLASSES 

Two  cases  of  cancer  were  reported  in  the  Mackay  Standard, 
Queensland,  Australia,  in  1902,  as  cured  by  the  use  of  mo- 
lasses. This  report  attracted  considerable  attention  at  the 
time,  and  while  the  diagnosis  of  the  cases  was  questioned,  the 
method  was  tried  at  the  Middlesex  Hospital.^  Several  cases 
of  cancer  in  different  parts  of  the  body  were  treated. 

According  to  the  first  reports,  the  molasses  was  given  in- 
ternally, commencing  with  one  dram  and  increasing  to  two 
ounces.  It  was  given  in  milk  or  water,  on  an  empty  stomach, 
four  times  daily.  The  molasses  employed  was  from  cane  sugar, 
pure  and  unrefined. 

In  the  Middlesex  Hospital  test  it  was  administered  locally 
as  well  as  internally.  Ulcerated  breasts  were  dressed  with  it, 
and  tampons  soaked  with  it  were  introduced  into  the  vagina 
and  brought  into  contact  with  the  ulcerated  svirface  in  cancer 
of  the  cervix.  Ulcerated  surfaces  were  kept  clean,  but  no' 
tendency  to  heal  was  noted.  It  lessened  the  fetor  of  uterine 
discharges,  but  did  not  affect  the  amount  of  the  discharge. 

Results  were  not  sufficiently  favorable  to  warrant  a  con- 
tinuance of  its  use,  and  nothing  is  now  heard  of  molasses  in  the 
treatment  of  cancer.  This  seems  to  be  one  of  the  few  instances 
in  which  the  test  sufficed  to  check  the  employment  of  an  appar- 
ently inefficacious  agent. 

1  Shaw-Mackenzie. — ' '  The  Nature  and   Treatment   of  Cancer, ' '  1905 

2  Archives  of  the  Middlesex  Hospital,  Vol.   II,  1904,  p.  93. 


260  THE   CANCER    PROBLEM 


VIOLET    LEAVES 

In  1901  a  paragraph  went  the  rounds  of  the  press  ^  describ- 
ing the  ''cure"  of  a  tumor  of  the  tonsil  by  the  application  of  a 
number  of  fomentations  made  from  an  infusion  of  green  violet 
leaves.  The  diagnosis  of  cancer  had  been  ''made  certain  by 
microscopic  examination  of  a  small  portion  removed."  The  pa- 
tient, in  gratitude  for  her  recovery,  had  some  leaflets  printed  de- 
scribing the  mode  of  application  of  the  remedy.  This  use  of  the 
violet  leaf  furnishes  an  excellent  illustration  of  the  persistence 
from  the  past  to  the  present  of  empirical  methods  of  treatment. 

The  violet  leaf,  according  to  the  Lancet,  figures  not  infre- 
quently among  the  recipes  of  the  old  Anglo-Norman  writers 
whose  manuscripts  are  preserved  in  the  British  Museum.  The 
pansy  ( Viola  Tricolor)  possesses  cathartic  and  emetic  quali- 
ties. ''The  dog  violet  is  vaguely  recorded  in  an  old  edition  of 
Balfour's  'Botany'  (1854)  to  have  been  at  some  time  or  other 
prescribed  for  'skin  diseases.'  In  the  days  of  the  Plantagenets. 
monkish  medical  writers  treated  most  diseases  with  the  violet^ 
whether  dog,  pansy,  or  sweet  March  they  do  not  state." 

"The  green  leaves  were  used  with  other  herbs  to  make 
plaisters  and  poultices  for  inflammations  and  swellings,"  ac- 
cording to  "The  English  Physician,"  Beissus — 1792,  of  Nicho- 
las Culpepper. 

Follow^ing  the  revival  of  1901,  the  treatment  of  inoperable 
cancer  by  means  of  the  extract  of  violet  leaves  was  heralded  in 
the  secular  press  in  1903.  The  first  case  reported  at  that  time 
was  one  of  "cancer  of  the  mouth."  The  diagnosis,  unlike  the 
one  in  1901,  was  not  confirmed  by  microscopic  examination, 
but  was  certified  by  competent  physicians.  The  daily  press 
exploited  the  case  as  one  of  "cure,"  and  for  a  time  violet  leaves 
were  in  demand,  and  much  valuable  time  was  wasted  with  this 
method  of  "tampering." 

The  extract  was  employed  locally,  by  means  of  lint  or  gauze 
soaked  in  the  fluid  and  applied  to  the  diseased  surfaces.  This 
dressing  was  changed  two  or  three  times  a  day,  according  to 
the  amount  of  discharge.  In  cancer  of  the  cervix,  vaginal 
tampons  soaked  in  the  extract  were  employed. 

The  Middlesex  Hospital  ^  tried  the  method  in  a  number  of 
cases  on  two  occasions.  In  the  first  report  it  was  stated  that 
in  no  single  case  did  any  good  result  from  the  method.  There 
were  no  relief  from  pain,  no  lessening  of  discharge,  no  abate- 

1  Lancet,  editorial,  November  23,  1901,  p.  1430. 

2  Archives  of  the  Middlesex  Hospital,  Vol.  II,  1904,  p.  91;  also,  Vol.  IV,, 
1906,  p.  75. 


THE   INVESTIGATION   OF   "CANCER   CURES"     261 

ment  of  other  symptoms.     In  one  case  of  cancer  of  the  breast 
there  was  an  increase  of  fetor. 

In  the  second  report,  of  twelve  cases  subjected  to  the  treat- 
ment, two  cases,  it  was  stated,  were  discharged  at  their  own 
request,  their  condition  being  unaltered ;  six  cases  died,  and  in 
the  remaining  four,  which  were  still  under  observation  when 
the  report  was  published,  the  disease  was  steadily  pursuing  its 
normal  destructive  course.  In  no  case  was  a  beneficial  result 
obtained,  although  temporarily  the  surfaces  of  ulcers  were 
cleaned  as  the  result  of  the  moist  application. 

THE    INVESTIGATION    OF    "aUACK    CURES" 

In  the  preceding  pages  we  have  discussed  the  testing  of 
such  proposed  methods  of  treatment  as  have  a  more  or  less 
plausible  excuse  for  their  existence  in  the  apparently  scientific 
basis  upon  which  they  are  evolved.  There  is  another  class  of 
"cures,"  however,  which  the  medical  profession  is  importuned 
to  employ,  sometimes  to  test  thoroughly,  which  has  no  excuse 
for  existence  save  the  greed  of  the  originators  or  the  blind  faith 
of  their  victims.  Yet  some  even  of  these  have  been  tested  in  a 
scientific  and  serious  manner  by  members  of  the  profession, 
some  have  been  investigated  by  legislative  bodies,  and  others 
have  been  exposed  to  the  searchlight  of  truth  by  medical  and 
secular  journals.  It  is  the  purpose  of  the  next  few  pages  to  give 
in  brief  detail  the  history  of  some  of  these  investigations. 

THE   MATTEI    "ELECTRICITIES" 

One  of  the  most  remarkable  instances  of  the  investigation 
by  the  medical  profession  of  a  "quack  cure"  for  cancer  is  that 
of  the  so-called  Mattel  method,  the  "electro-homeopathic  sys- 
tem," the  "new  medical  science." 

Count  Mattel  and  his  remedies  were  first  brought  promi- 
nently before  the  notice  of  the  English-speaking  world  through 
an  article  by  Lady  Paget,  which  appeared  in  the  National 
Review  in  May,  1890,  and  later  by  an  article  by  the  late  W.  T. 
Stead,^  editor  of  the  Review  of  Reviews. 

1  Stead,  W.  T.— "Can  Cancer  Be  Cured?  A  Visit  to  Count  Mattei:  His 
Challenge  to  the  Faculty.  With  Letters  from  Prof.  Huxley,  Prof.  Tyndall, 
Sir  Morell  Mackenzie,  Prof.  Eay  Lankaster,  and  Others,"  Review  of  Be- 
views,  January,   1891.     See  also: 

Mattei,  Caesar. — "Electro-Homeopathy.  The  Principles  of  a  New  Sci- 
ence, Discovered  by  Count  Mattei  of  Bologna, ' '  1880. 

Kennedy,  S. — "Is  Cancer  Curable?  The  Cancer  Controversy:  Mattei  v. 
the  Knife;  hovr  it  began,  how  it  ended;  with  an  epitome  of  Mattei  treat- 
ment of  cancer  and  general  diseases,"  London,  1891. 


262  THE   CANCER    PROBLEM 

The  latter  article  sets  forth  the  ^vhole  storv  in  so  interesting 
a  fashion  that  we  quote  from  it  freely.  It  gives  so  plainly  the 
attitude  of  a  large  part  of  the  public,  even  of  the  most  intelli- 
gent public,  concerning  the  efforts  of  the  medical  profession 
to  solve  the  cancer  problem,  that  it  "points  a  moral  and  adorns 
a  tale." 

"Can  cancer  be  cured?"  is  the  opening  question.  "Accord- 
ing to  the  doctors,"  Mr.  Stead  continued,  "it  is  incurable.  Cut 
it  out  when  it  first  appears,  and  you  may  have  a  chance.  Let  it 
alone,  and  you  will  die  in  agony.  Medicine  can  do  nothing, 
but  one  can  administer  a  drug  to  dull  pain;  the  knife  at  the 
beginning  and  morphine  at  the  end — these  are  the  Alpha  and 
Omega  of  medical  science  in  dealing  with  this  deadly  disease. 
Count  Mattel  asserts  that  cancer  can  be  cured — that  he  has 
cured  it,  and  is  curing  it,  and  he  challenges  scientific  examina- 
tion. That  challenge  must  be  taken  up,  and  in  the  following 
article,  I  venture  to  hope  the  case  is  so  stated  as  to  render  it 
impossible  any  longer  to  refuse  the  inquiry  for  which  the 
Count  pleads." 

"Count  Mattel,"  continued  Mr.  Stead,  "is  the  Italian  noble- 
man whom  Lady  Paget  visited  after  his  medicines  had  cured 
her  husband,  now  his  Majesty's  Ambassador  to  Vienna.  It 
was  her  paper  in  the  National  Eeview,  of  May,  partially  re- 
printed in  these  pages,  that  first  drew  general  attention  to  the 
fact  of  his  existence,  although  a  short  time  previously  Com- 
missioner Booth-Tucker  had  spoken  of  his  medicines.  Com- 
missioner Tucker,  when  returning  from  India  by  the  Brindisi 
route,  passed  the  Count's  castle  at  Riola,  called  upon  him,  was 
very  favorably  impressed  with  the  Count's  personality,  and 
came  away  believing  almost  as  much  in  Count  Mattel  as  he  had 
previously  learned  to  believe  in  the  Mattel  medicines." 

The  fact  that  Commissioner  Booth-Tucker  had  been  cured 
by  the  Mattel  medicines  of  a  chronic  dysentery  which  had  baf- 
fled the  Anglo-Italian  medical  profession  for  years,  did  not 
especially  interest  Mr.  Stead,  and  it  was  only  after  the  ap- 
pearance of  Lady  Paget's  article,  which  was  emphasized  by  a 
second  from  the  same  pen,  that  the  editor  of  the  Eeview  of 
Reviews  began  to  take  a  keen  personal  interest  in  the  Count  and 
his  medicines.  "For,"  as  he  said,  "this  was  not  the  testimony 
of  a  nobody.  It  was  published  evidence  of  a  lady  whose  hus- 
band has  achieved  the  highest  position  in  the  diplomatic  ser- 
vice— a  lady,  moreover,  who  could  not  possibly  have  any  per- 
sonal or  interested  motive  in  recommending  the  remedies  to 
the  world.  There  was,  of  course,  the  usual  condemnation  pro- 
nounced by  the  orthodox  faculty.     Without  that,  no  new  dis- 


THE   INVESTIGATION   OF   "CANCER   CURES"      263 

covery  can  be  deemed  worthy  of  notice  by  the  outside  pnbh'c. 
Such  censure  indeed  is  the  prima  facie  intimation  that  there 
may  be  something  in  it." 

According  to  Lady  Paget  and  other  creditable  witnesses, 
this  "philanthropic  Italian  noble"  had  discovered  certain  rem- 
edies which  she  declared  to  possess  an  almost  supernatural 
efficiency  for  curing  disease  incurable  by  the  aid  of  the  phy- 
sician. "And  not  one  of  all  the  Faculty,"  said  Mr.  Stead, 
"deemed  it  worth  while  so  much  as  to  inquire  whether  or  not 
these  things  were  so." 

Shortly  after  his  interest  had  been  thoroughly  aroused  in 
the  "electro-homeopathic"  system  of  medicine,  Mr.  Stead  vis- 
ited Mrs.  Booth,  wife  of  the  late  founder  of  the  Salvation 
Army,  who  was  at  that  time  upon  her  death  bed,  the  victim  of 
cancer.  "We  talked  much,"  he  continued,  "of  cancer  and  the 
possibility  of  its  cure.  Mrs.  Booth  told  me  that  one  of  the 
saddest  thoughts  which  darkened  her  closing  hours,  was  that 
the  long  course  of  experiment  to  which  she  had  permitted  her- 
self to  be  subjected  had  not  resulted  in  the  discovery  of  any 
sure  mode  of  treatment  that  could  cope  with  this  terrible 
scourge.  .  .  .  'What,'  said  I,  'of  the  Mattei  treatment  ?'  'His 
is  the  best,'  she  said  emphatically.  'His  green  "Electricity," 
what  would  I  have  done  without  it  ?  I  have  constantly  applied 
it,  and  it  alone  has  given  me  any  relief  from  this  terrible  pain.' 
'But,'  said  I,  'his  treatment  did  not  cure  you.'  'No,'  said  she, 
'it  did  not ;  but  that  is  because  I  did  not  stick  to  it.  It  is  so 
slow  and  tedious  to  be  always  taking  these  little  sips,  and  after 
a  time  I  gave  it  up.'  " 

When  Mr.  Stead  reminded  her  that  her  family  considered 
the  remedies  to  have  been  thoroughly  tested  in  her  case,  she 
emphatically  assured  him  that  she  was  dying,  not  so  much  be- 
cause of  the  cancer  as  because  she  had  neglected  to  use  the 
Mattei  remedies.  She  believed  that  if  she  had  persisted  in 
their  use  she  might  have  lived  many  years.  So  great  was  her 
confidence  in  the  remedies  that  she  made  her  children  promise 
her  that  if  they  were  attacked  by  the  disease  which  was  about 
to  carry  her  off  they  would  go  to  Count  Mattei  and  place  them- 
selves under  his  treatment. 

This  incident  seemed  to  deeply  impress  Mr.  Stead,  and  he 
began  his  investigation  into  the  method.  In  Lad}^  Paget's 
article  reference  was  made  to  a  physician  who  practiced  suc- 
cessfully in  London  with  the  Mattei  remedies.  Mr.  Stead 
called  upon  the  gentleman,  who  assured  him  that  what  Lady 
Paget  had  said  was  true.  Shortly  after  this  the  doctor  reported 
to  Mr.  Stead  a  case  of  malignant  cancer  cured  by  the  use  of 


264  THE   CANCER   PROBLEM 

the  Mattel  remedies.  He  promised  to  have  the  patient  come 
from  Scotland  to  London,  and  to  submit  the  patient  and  her 
history  to  Dr.  Herbert  Snow,  of  the  Cancer  Hospital,  and  any 
committee  of  experts  whom  he  might  select  from  the  medical 
faculty. 

So  impressed  was  Mr.  Stead  by  all  this  evidence  that  he  im- 
mediately made  a  visit  to  Count  Mattei  in  his  castle,  La  Ro- 
chctta,  in  Jtaly.  From  the  Count,  who  was  then  eighty-two 
years  old,  he  learned  the  following  story  of  the  "wonderful 
discovery" : 

When  Parliamentarism  gave  way  to  Revolution  in  Italy, 
Count  Mattei  gave  up  the  political  life  of  which  he  had  been 
a  part,  and  devoted  his  life  to  the  study  of  agriculture,  botany, 
and  chemistry.  The  discovery  of  his  remedies  was  directly 
traceable  to  his  observation  of  the  successful  efforts  of  a  shep- 
herd dog  to  cure  himself  of  a  loathsome  mange  by  means  of 
an  herb.  The  Count  gathered  some  of  the  leaves  of  the  plant, 
distilled  them,  and  tried  the  product  on  a  patient  suffering 
from  scrofula.  Math  wonderful  results.  By  degrees  he  suc- 
ceeded, according  to  his  story,  in  compounding  eight  or  ten 
medicines  and  five  "electricities,"  with  which  he  treated  all 
manner  of  diseases,  cancer  among  the  number.  He  was  a 
follower  of  Hahnemann,  except  that  he  believed  in  combat- 
ing the  causes  of  disease  rather  than  its  outward  manifesta- 
tions. Mr,  Stead  did  not  seem  to  be  impressed  with  the  ab- 
surdity of  this  statement  from  one  who  had  had  no  medical 
training. 

With  all  earnestness  Mr.  Stead  continued  his  account :  "His 
herbs  are  good,  no  doubt;  but  the  grand  secret  is  the  fixing  in 
the  remedy  of  a  mysterious  something  which  he  calls  the  elec- 
trical principle.  This,  he  asserts,  is  the  vital  principle  of  the 
universe,  and,  as  far  as  I  could  make  out,  is  cousin-german  to 
the  astral  fluid  of  the  occultists,  or  the  strange  etheric  force  of 
Keeley.  Count  Mattei,  however,  knows  nothing  of  the  astral 
force,  or  of  Keeley's  motor.  He  maintains  that  he  knows  how 
to  make  herbal  decoctions  instinct  with  a  potent,  vital,  elec- 
trical force  which  enables  them  to  work  wonders." 

Pope  Pius  IX,  according  to  the  story,  had  placed  at  the 
Count's  disposal  a  part  of  the  hospital  of  St.  Teresa  in  Rome, 
where  he  is  said  to  have  achieved  some  marvelous  cures  of  can- 
cer in  an  incredibly  short  time.  That  was  back  in  the  sixties 
and  seventies.  He  is  said  not  to  have  sold  his  remedies  at  that 
time,  but  to  have  given  them  to  anyone  who  asked.  He  had 
also  opened  a  dispensary  in  Bologna,  where,  from  1865  to  1867, 
he  claimed  to  have  cured  an  immense  number  of  people.     The 


THE  INVESTIGATION  OF  "CANCER  CURES"     265 

^'Eegular  Faculty"  was  hostile  to  him.  He  appealed  to  the 
Church  to  add  the  healing  of  bodies  to  the  healing  of  souls, 
and  to  arm  every  parish  with  the  cheap  and  efficacious  rem- 
edies which  his  discovery  placed  within  their  reach.  He  issued 
a  circular  to  this  effect  to  the  ministers  of  all  religions,  but 
received  no  response. 

The  hostility  of  the  orthodox  medical  profession,  together 
with  threats  of  personal  violence,  led  the  Count  to  seek  the 
seclusion  of  the  fortress  of  La  Kochetta,  where  Mr.  Stead 
found  him. 

In  time  the  modern  medical  laws  of  Italy  had  prohibited 
the  Count  from  practicing  the  healing  art,  inasmuch  as  he  held 
no  medical  diploma ;  and  another  law,  passed  about  the  time  of 
Mr.  Stead's  visit  to  the  Count,  prohibited  the  sale  in  Italy  of 
a  remedy  the  nature  of  which  was  not  sufficiently  stated. 

The  excuse  which  Count  Mattel  made  for  not  giving  to  the 
world  so  beneficial  a  secret,  was  the  usual  one — that  he  could 
not  be  sure  that  others  would  manufacture  the  compound  with 
the  care  and  exactitude  upon  which  its  effect  depended. 

From  the  distributing  office  in  Bologna  it  was  said  that 
about  a  million  phials  of  the  little  granules  were  sent  out  every 
year,  and  as  many  bottles  of  the  "electricities,"  and  boxes  of 
the  ointment.  These  went  practically  all  over  the  world.  The 
Matteiists  published  monthly  and  fortnightly  bulletins  of  the 
"electro-homeopathic  system,"  which  also  had  a  very  wide 
distribution. 

"It  was  curious,"  said  Mr.  Stead,  "to  hear  the  Count  talk 
of  cancer  cures  as  if  they  were  among  the  ordinary  every-day 
incidents  of  life."  "Imagination  will  not  cure  a  cut,  nor  will 
imagination  cure  a  cancer,"  yet  the  Matteiists  claimed  to  do 
both.  It  would  seem,  however,  .that  even  the  imagination  of  a 
"high  potency"  Hahnemannist  could  hardly  be  equal  to  con- 
ceiving of  a  malignant  cancer  being  influenced  by  a  pin-head 
granule  of  one  of  the  Mattel  "electricities"  dissolved  in  a  glass- 
ful of  water,  a  teaspoonful  of  this  taken,  the  rest  thrown  away, 
this  spoonful  mixed  with  another  tumblerful  of  water,  a  spoon- 
ful of  this  last  glassful  taken,  the  rest  thrown  away,  and  this 
spoonful  mixed  with  another  glassful  of  water,  the  last  being 
sipped  by  the  patient  afflicted  with  cancer.  And  yet  such  was 
the  remedy  which  the  Matteiists  and  their  followers  challenged 
the  medical  profession  to  test! 

Full  of  enthusiasm,  Mr.  Stead  returned  to  London,  bent 
upon  forcing  the  medical  world  to  recognize  the  wonderful 
discovery  of  this  Italian  Count.  Two  cases  of  sarcoma,  so 
pronounced  by  pathological  report,  which  had  been  cured  by 


266  THE  CANCER   PROBLEM 

the  ''electricities/'  clinched  his  determination.  After  collect- 
ing what  he  considered  suihcient  evidence,  Mr.  Stead  addressed 
to  the  medical  profession  a  letter  asking  that  a  scientific  test 
and  investigation  be  made.  In  the  article  from  which  we  have 
quoted,  some  of  the  replies  are  published.  It  was  left  to  Sir 
Slorell  ]\Iackenzie,  however,  to  mal<:e  a  suggestion  which  met 
with  Mr.  Stead's  approval.  It  was  to  the  effect  that  a  commit- 
tee be  appointed  for  the  purpose  of  investigating  the  matter, 
and  that  a  small  hospital  be  opened  for  receiving  the  patients 
to  be  treated.  lie  volunteered  to  serve  as  a  member  of  the 
committee. 

Inasmuch  as  certain  reg-ular  practitioners  of  medicine  had 
begun  to  employ  the  method,  and  as  its  cause  had  been  cham- 
pioned in  the  public  press  by  such  prominent  persons  as  Lady 
Paget  and  Mr.  Stead,  it  was  deemed  a  public  service  to  bring 
to  light  the  true  character  of  the  treatment.  To  this  end, 
following  the  suggestion  of  Sir  Morell  Mackenzie,  the  Mattei 
Investigation  Committee  was  formed. 

The  members  of  the  Committee  were  Sir  Morell  Mackenzie, 
Mr.  Lawson  Tait,  and  G.  W.  Potter.  After  the  death  of  Sir 
Morell  Mackenzie,  Mr.  H.  A.  Peeves,  P.R.C.S.E.,  and  Mr. 
John  Hopkins,  F.R.C.S.,  became  members  of  the  Committee, 
and  the  investigation  was  continued.  The  report  of  the  Com- 
mittee was  published  in  the  British  Medical  Journal  of  Au- 
gust 13,  1892,  p.  369. 

Despite  the  personal  opinions  of  individual  members  of  the 
Committee,  it  was  determined  to  investigate  the  treatment  thor- 
oughly, and  to  report  results  faithfully.  It  was  demanded  that 
the  Matteiists  at  least  tell  of  what  their  remedies  were  com- 
posed, but  of  course  this  was  refused.  The  treatments  were 
not  to  be  administered  by  the  members  of  the  Committee,  who 
were  merely  to  "see  and  admit  cures  in  the  making,"  just  as 
if  asked  to  "see  and  admit  the  reality  of  the  miracles  at 
Lourdes."  The  Matteiists  were  to  give  the  treatments,  and 
this  they  agreed  to  do  in  "bona-fide"  cancer  cases,  provided  they 
were  in  the  "first  or  second  stages." 

The  terms  of  the  investigation  having  been  settled,  the  cases 
were  sent  in  to  the  Matteiists  for  acceptance  or  rejection. 
Pealizing  by  this  time  that  they  were  face  to  face  with  possible 
exposure,  they  began  to  hedge,  and  patient  after  patient  of 
the  many  sent  in  was  rejected.  Finally,  however,  five  women 
with  cancer  of  the  breast  were  selected  and  the  treatments 
were  begun. 

The  cases  were  watched  from  week  to  week  by  a  graduate  in 
medicine  whom  the  Committee  employed  for  the  purpose,  and 


THE  INVESTIGATION  OF  "CANCER   CURES"     267 

the  members  themselves  regularly  inspected  them.  Again 
realizing  that  the  investigation  v^^as  to  be  a  thorough  one,  the 
Matteiists  lost  courage,  and,  through  their  friend  and  cham- 
pion, the  editor  of  the  Review  of  Reviews,  endeavored  to 
end  it. 

The  Editor  wrote  to  the  Committee  that  the  cases  were  prov- 
ing to  be  very  stubborn  ones,  and  inasmuch  as  people  were  anx- 
iously awaiting  their  report,  it  was  suggested  that  they  see 
some  "cured"  cases  and  make  their  report  from  these.  Nat- 
urally this  was  refused. 

The  members  of  the  Committee  had  agreed  among  them- 
selves, entirely  apart  from  any  agreement  with  the  Matteiists, 
to  give  out  for  publication  no  authorized  statement  during  the 
course  of  the  investigation.  When,  however,  after  the  treat- 
ment had  continued  for  a  year,  and  when  an  obscure  medical 
journal  published  a  statement  concerning  the  prejudiced  atti- 
tude of  the  members  of  the  Committee,  this  was  immediately 
seized  upon  by  the  Matteiists  as  a  violation  of  agreement,  and 
they  refused  absolutely  to  continue  the  treatment  under  the 
observation  of  the  Committee  or  their  paid  representative. 
Nothing  that  their  friend,  Mr.  Stead,  could  say  had  any  weight 
with  them.  They  saw  in  this  their  last  chance  to  escape  being 
completely  found  out,  and  therefore  ignominiously  abandoned 
their  patients  and  gave  up  the  test  which  the  overzealous 
faith  of  their  friends  had  unwittingly  brought  upon  them.  The 
Committee  then  rendered  its  report. 

The  potions  which  the  Matteiists  used  and  which  they  called 
"^^electricities"  were  subjected  to  chemical  analysis.  They 
gave  no  other  reaction  than  that  of  distilled  water ! 

It  is  hardly  necessary  to  add  that  not  one  of  the  five  cases 
was  in  any  way  benefited  by  the  treatment. 

The  report  ended  with  the  following  words :  "There  is  noth- 
ing more  to  be  said.  The  story  is  as  old  as  the  world.  The 
savage  trusts  to  his  amulet;  the  civilized  man,  both  in  the 
upper  and  lower  circles,  submits  himself  with  childish,  if  not 
childlike,  simplicity  to  the  presence  of  the  quack.  It  is  a 
strange  world ;  but,  such  as  it  is,  open  and  honorable  medicine 
has  lived  and  worked  in  it,  and  must  make  the  best  it  can  of 
so  wonderfully  varied  an  environment." 

It  may  be  stated  that  the  members  of  the  Committee,  feeling 
so  strongly  that  the  public  was  being  deceived  by  the  preten- 
tions of  Count  Mattei  and  his  followers,  and  that  the  vaunted 
"cure"  possessed  no  efficiency  whatever,  refused  to  begin  the 
investigation  without  first  emphasizing  their  opinion  to  each 
of  the  five  patients  selected,  advising  them  to  seek  hospital  care 


268  THE   CAN'CER    PROBLEM 

and  proper  surgical   nttciition.      This  they   refused   to   do,    so 
strong  was  their  belief  in  the  new  remedy. 

The  Mattel  ''Electricities"  were  still  quoted  in  European 
wholesale  drue;  lists  as  late  as  1006. 


THE  CARDIGAN  (WALES)   "CANCER  CURERS" 

It  might  reasonably  be  inferred  that  such  an  investigation 
as  that  devoted  to  the  Mattel  treatment,  which  was  watched 
with  particular  interest  by  the  British  medical  profession  and 
the  public,  would  have  been  sufficient  to  settle  the  question  of 
the  attitude  of  the  profession  with  reference  to  "cures"  for 
cancer,  and  to  absolve  them,  individually  and  as  a  body,  from 
further  charges  of  unwillingness  to  Investigate  such  methods. 
This  was  not  the  case.  In  about  fifteen  years  history  repeated 
Itself,  and  the  British  public  and  medical  profession  found 
Mr.  Stead  once  more  championing  a  "cancer  cure,"  the  avowed 
purpose  being,  of  course,  the  desire  to  benefit  the  victims  of 
the  disease.-^ 

This  time  he  Importuned  the  Cancer  Research  Committee 
to  Investigate  the  method  of  the  "Cancer  Curers"  of  Cardigan, 
South  Wales.  Upon  their  refusal,  and  their  reminder  of  the 
Mattel  fiasco,  the  editor  satirically  remarked:  "Supposing  an 
angel  came  from  Heaven  with  an  infallible  specific  to  heal  in- 
stantaneously every  case  of  cancer  submitted  for  treatment, 
the  Cancer  Research  Committee  would  refuse  to  recognize  the 
sudden  disappearance  of  caflcer  from  the  maladies  of  mankind 
unless  they  were  informed  of  the  precise  ingredients  of  the 
specific." 

This  arraignment  was  made  apropos  of  one  of  the  most 
characteristically  "quack"  remedies  which  has  ever  come  prom- 
inently before  the  public  notice. 

Daniel  and  John  Evans,  two  farmers  near  Cardigan,  had 
been  "curing  cance.r"  for  a  number  of  years,  but  it  was  not 
until  190Y  that  their  fame,  having  reached  the  local  news- 
papers, extended  throughout  Wales,  and  thence  to  the  country 
at  large. 

My  attention  was  first  directed  to  the  "Cancer  Curers"  by 
an  article  which  appeared  in  the  BrooMyn  Daily  Eagle,  July 
14,  1907.  Shortly  thereafter,  at  my  request,  Dr.  Mary  Hess 
Brown,  of  ISTew  York  City,  who  was  visiting  London  at  the 
time,  went  to  Cardigan  to  investigate  the  claims  of  these  men. 

It  was  found  that  these  rough,  uneducated  men  claimed  to 
^Brit.  Med.  Jour.,  "Cancer  Cures,"  editorial,  March  23,   1907,  p.   703. 


THE  INVESTIGATION  OF  "CANCER   CURES"     269 

cure  cancer  by  means  of  an  ointment  made  entirely  from 
herbs,  according  to  their  statement,  containing  no  mineral 
caustic  of  any  kind.  This  ointment  was  applied  to  the  surface 
of  the  tumor  (they  treated  only  "external"  tumors,  and  by 
preference  only  tumors  which  had  not  been  cut).  Tumors 
which  had  been  operated  upon  they  likened  to  a  tree  cut  away 
from  its  roots,  and  such  a  tumor  was  unsuccessfully  treated  by 
them  because  they  had  nothing  into  which  to  draw  the  "roots." 
They  claimed  to  shrink  the  "roots"  of  the  growth  np  into  the 
main  tumor-mass,  which,  when  this  has  taken  place,  falls  ofP, 
"like  a  ripe  apple  from  a  tree." 

The  ointment,  or  oil,  which  forms  the  main  part  of  the 
treatment,  was  zealously  guarded  from  the  view  of  even  the 
patients,  being  kept  in  a  bottle  covered  with  black  cloth.  Daily 
applications  were  made  over  the  affected  part,  each  patient 
being  required  to  bring  his  or  her  own  brush  to  the  "surgery" 
for  the  purpose.  After  the  application  of  the  ointment  the 
brush  was  carefully  squeezed,  the  excess  being  put  back  into 
the  bottle,  and  the  brush  washed  and  dried  before  the  patient 
was  allowed  to  go.  From  these  precautions  it  will  easily  be 
seen  that  it  was  not  a  simple  matter  for  members  of  the  medi- 
cal profession  to  obtain  a  specimen  of  the  ointment  for  analysis. 
It  was  thought  by  some,  however,  to  be  a  spurge  (presumably 
Euphorbia  resinifera) ,  a  caustic  plant ;  others  were  of  the  opin- 
ion that  it  was  a  chlorid  of  zinc  in  different  solutions. 

Following  the  application  of  the  ointment  the  patient  was 
instructed  to  apply  water  in  which  marshmallow  leaves  had 
been  boiled.  Sometimes  they  were  instructed  to  keep  the  part 
covered  with  a  cabbage  leaf. 

This  treatment  was  continued  for  weeks  and  months,  and 
doubtless  in  many  instances  was  repeated  upon  more  than  one 
occasion  during  the  life  of  the  patient. 

In  the  British  Medical  Journal  of  December  5,  1908,  J. 
Lynn  Thomas,  C.B.,  F.KC.S.,  Surgeon  to  the  Cardiff  In- 
firmary, reported  a  case  of  cancer  of  the  breast  "cured"  by  the 
Cardigan  "Cancer  Curers,"  with  plates  illustrating  how  suc- 
cessfully this  "cure"  was  effected.  This  patient  had  received 
daily  treatments  for  eight  months,  at  the  end  of  which  time  the 
cancer  was  steadily  growing.  "Eight  months,"  said  Mr. 
Thomas,  "of  daily  applications  of  'oil'  to  the  whole  skin  of  a 
woman's  breast,  with  cancer  steadily  growing  and  creeping  be- 
neath the  skin,  is  a  picture  for  the  public  to  ponder,  and  for  the 
public  press  which  encouraged  scores  of  cancer  victims  to  mi- 
grate to  Cardigan,  seriously  to  consider."  "The  'cure,'  "  he  con- 
cludes, "is  worse  than  a  farce,  and  one  may  ask  how  is  suffering 


270  THE   CANCER    PROBLEM 

liiimanity  to  be  saved  from  the  tragedy  of  self-destruction  by 
faith  in  these  direful  'Miracles.'  " 

The  British  Medical  Association  investigated  this  "cure," 
and  in  the  book  entitled  "Secret  Remedies.  What  they  Cost 
and  What  they  Contain,''  published  in  1909,  are  given  the 
results  of  their  examination.  One  of  the  so-called  cancers 
which,  like  the  ripe  apple,  had  fallen  from  the  tree,  and  had 
been  placed  in  a  bottle  and  given  to  the  patient,  was  examined 
microscopically.  This  was  found  to  consist  of  "crusts  formed 
of  sloughing  parts  of  the  skin  and  intlammatory  exudation, 
the  whole  being  such  a  mass  as  might  be  produced  by  the  use  of 
an  escharotic."  When  these  crusts  were  subjected  to  chemical 
analysis  they  were  found  to  contain  zinc  chlorid  in  considerable 
amount,  together  with  a  very  appreciable  quantity  of  an  in- 
soluble compound  of  lead.  The  healing  pill  to  which  reference 
had  been  made  was  also  analyzed,  and  was  found  to  contain  27 
per  cent,  of  oil  of  turpentine,  the  remainder  consisting  princi- 
pally of  an  ordinary  saponifiable  oil,  probably,  according  to 
the  report,  cotton-seed  or  olive  oil.  In  addition  there  was  a 
considerable  amount  of  deposit  which  proved  to  be  composed 
almost  wholly  of  barium  sulphate,  a  very  insoluble  salt,  known 
to  water-color  painters  as  "permanent  white."  It  was  with 
characteristic  disregard  for  the  truth,  then,  that  the  statement 
was  made  that  the  treatment  involved  the  use  of  no  mineral 
caustic. 

Such  was  the  "cure"  which  called  forth  the  above-quoted 
satirical  accusation  against  the  medical  profession. 


THE    "AESIAB    CANCER    CURE" 

One  of  the  most  unique  investigations  of  a  so-called  cancer 
cure  is  that  embodied  in  the  "Cape  of  Good  Hope  Report  of 
the  Select  Committee  on  Mrs.  van  ISTiekerk's  Petition,"  pub- 
lished at  Cape  Town,  South  Africa,  in  1906. 

This  committee  was  appointed  by  Orders  of  the  House  of 
Assembly,  on  petitions  presented  on  behalf  of  Mrs.  ISTiekerk, 
with  power  to  take  and  call  for  papers.  It  consisted  of  seven 
laymen  and  four  physicians.  Seven  days  were  consumed  in 
taking  the  evidence,  and  two  days  more  in  deliberation  and 
in  the  formulation  of  the  report.  The  report,  as  printed,  em- 
bodies the  verbatim  testimony  of  all  the  witnesses,  with  an 
appendix  which  gives  the  various  petitions  upon  which  the  in- 
vestigation was  based.     An  abstract  of  the  report  is  here  given. 

The  various  petitions  prayed  that  Mrs.  van  Xiekerk  be  au- 


THE   INVESTIGATION   OF   "CANCER   CURES"     271 

thorized  to  treat  cases  of  cancer  and  other  sores  by  means  of 
her  three  preparations,  the  "Aesiab  Cancer  Cure,"  a  ^'healing 
ointment,"  and  a  ''blood  purifying"  mixture.  The  most  im- 
portant of  these  was  the  first,  which  consisted  of  about  45  per 
cent,  tartar  emetic,  5  per  cent,  chalk,  and  50  per  cent.  lard. 
Mrs.  van  Niekerk  had  received  no  medical  education;  she  had 
no  scientific  knowledge  of  cancer  or  of  the  action  of  tartar 
emetic,  nor  did  she  claim  to  be  able  to  discriminate  in  all  cases 
between  cancer  and  syphilis. 

At  the  suggestion  of  the  committee,  Mrs.  van  ISTiekerk  sub- 
mitted three  patients  who  had  been  treated  and  "cured"  of 
cancer  by  her  method.  One  of  these  came  by  invitation  from 
the  committee.  The  only  case  from  which  they  could  obtain 
any  indisputable  evidence  concerning  the  nature  of  the  "can- 
cer" was  that  of  the  woman  who  had  used  the  ointment  for 
two  years  and  four  months  to  remove  an  alleged  cancer  of  the 
breast.  In  consequence  of  the  treatment  about  three-quarters 
of  the  breast  had  been  removed  in  pieces  about  the  size  of  wal- 
nuts. These  pieces  the  patient  had  preserved,  and  they  were 
subjected  to  microscopical  study  by  the  Medical  Officer  of 
Health  for  the  Colony.  Despite  a  very  careful  examination, 
this  official  was  unable  to  find  any  trace  of  cancer. 

While  there  was  no  evidence  of  a  cure  in  any  authenticated 
case  of  cancer,  the  details  of  two  deaths  had  been  submitted 
to  the  committee.  In  both  cases  the  treatment  had  caused 
needless  pain  and  suffering  and  appeared,  not  only  to  have  has- 
tened the  death,  but  to  have  made  it  horrible. 

The  various  petitioners  had  emphasized  the  philanthropic 
side  of  Mrs.  van  ISTiekerk's  treatment.  The  committee  found, 
on  the  contrary,  that  she  had  charged  an  exorbitant  price  for 
the  ingredients,  and  had  made  claims  which  raised  false  hopes 
and  caused  deplorable  loss  of  time. 

The  committee  denied  the  prayers  of  the  various  petitioners, 
and  in  conclusion  regretted  that  the  sale  of  such  remedies 
should  be  tolerated. 


DAVIS    CANCER    "CURE"    (MELBOURNi:,    AUSTRALIA) 

Another  interesting  example  of  legislative  investigation  of 
an  alleged  cure  of  cancer  is  found  in  the  Davis  Cancer  Cure, 
Melbourne,  Australia.^ 

1 ' '  Cube  of  Cancer. — Eeport  of  Board  Appointed  to  Inquire  into  the 
Claims  Made  by  Mr.  J.  A.  Davis  in  Respect  of  His  Alleged  Eemedy  for 
Cancer.  Presented  to  Both  Houses  of  Parliament  by  His  Excellency's 
Command."     Victoria,  1911. 


272  THE   CANCER   PROBLEM 

The  Board  was  appointed  and  was  constituted  by  an  Order 
in  Council  in  December,  190G,  "to  inquire  on  oath,  investigate, 
and  report  as  to  the  efficacy  or  otherwise"  of  the  alleged  cure. 
The  Board  consisted  of  ten  members,  four  of  whom  were  phy- 
sicians. An  officer  of  the  Health  Department  was  Secretary. 
It  opened  its  meetings  in  January,  1907,  and  held  fourteen 
meetings  between  that  time  and  March,  1908,  when  it  ad- 
journed, in  order  to  allow  Mr.  Davis,  the  "cancer  curer,"  to 
complete  the  treatment  of  a  number  of  cases  under  observation. 
A  Progress  Report  was  rendered  at  that  time.  The  Board 
resumed  its  sessions  in  May,  1900,  and  held  one  meeting. 

"After  having  ascertained  that  none  of  the  cases  which  were 
under  treatment  when  the  Board  adjourned  in  1908,  and  which 
were  as  far  as  practicable  kept  under  observation  for  more 
than  twelve  months,  could  be  produced  as  cases  of  successful 
treatment,  the  Board  decided,  in  view  of  the  unsatisfactory 
attitude  of  Mr.  Davis  throughout  the  investigation,  to  bring  the 
inquiry  to  a  close." 

The  claims  made  by  Mr,  Davis  on  behalf  of  his  treatment 
were  as  follows: 

"1.  That  the  alleged  remedy,  a  local  application,  is  ef- 
fectual in  the  treatment  of  cancer,  and  that,  by  destroying  and 
causing  the  removal  of  the  cancerous  growth,  it  cures  the  dis- 
ease, leaving  no  tendency  to  recurrence. 

"2.  That  the  remedy  in  destroying  cancerous  growths  exer- 
cises a  selective  action  and  does  not  affect  healthy  tissues. 

"3.  That  the  remedy  is  unique  and  is  not  in  any  way  iden- 
tical with  other  destructive  agents  (caustics  or  escharotics) 
which  have  in  the  past  been  used  for  the  removal  of  cancerous 
and  other  growths,  and  that  it  is  used  solely  by  him." 

According  to  the  report,  Mr.  Davis,  at  the  beginning  of  the 
inquiry,  furnished  a  list  of  persons  whom  he  desired  to  call  as 
witnesses.  Many  of  these,  he  stated,  had  been  treated  for  and 
cured  of  cancer ;  others  were  patients  still  under  treatment.  He 
also  named  a  number  of  medical  men  who  had  previously 
treated  patients  included  in  the  list. 

"The  Board  resolved  to  examine  those  persons  who  were 
said  to  be  still  under  treatment,  and  in  the  first  instance  to 
make  inquiries  by  letter  from  those  stated  to  have  been  cured. 
Those  patients  were  requested  to  furnish  the  names  of  medical 
men  who  had  attended  them,  and  full  information  was  after- 
ward sought  from  each  of  the  practitioners  named.  It  was 
further  decided  that  any  case  in  regard  to  which  the  informa- 
tion thus  elicited  gave  any  indication  of  the  disease  having 
been  cancer  should  subsequently  be  examined. 


THE   INVESTIGATION   OF   "CANCER   CURES"     273 

"Mr.  Davis  was  also  specially  invited  at  the  outset  of  the 
inquiry  to  submit  for  examination  and  investigation  all  cases 
which  from  that  time  presented  themselves  for  treatment  by 
him,  and  were,  in  his  opinion,  cases  of  cancer.  It  was  ar- 
ranged that  all  the  medical  members,  or  as  many  as  were  avail- 
able at  any  time,  should  examine  such  cases  at  any  convenient 
time,  if  brought  or  sent  by  Mr.  Davis  to  the  Chairman  before 
the  commencement  of  treatment.  The  purpose  of  this  arrange- 
ment was  to  allow  of  a  diagnosis  being  made  before  the  growth 
or  diseased  part  had  been  altered  by  treatment,  seeing  that 
caustic  agents  may  so  modify  the  tissues  attacked  by  them  as 
to  render  them  unrecognizable.  It  was  pointed  out  to  Mr. 
Davis  that  the  cases  which  the  Board  could  have  under  ob- 
servation and  within  its  knowledge  from  the  inception  until 
the  termination  of  treatment  would  afford  the  best  and  most 
unequivocal  evidence  of  the  efficacy  or  otherwise  of  the  agents 
employed  by  him.  It  was  also  explained  that  cases  examined 
after  treatment  had  commenced,  or  after  alleged  cure,  would, 
unless  the  Board  could  examine  the  growth  removed,  and  could 
identify  it  with  the  case,  necessarily  carry  less  weight ;  and, 
further,  that  old  cases  presented  long  after  alleged  cure  would 
for  the  purpose  of  the  inquiry  be  of  small  value  unless  the 
history  and  the  collateral  evidence  as  to  the  nature  of  the 
growth  were  unequivocal  and  positive. 

"Mr.  Davis  agreed  to  comply  with  the  Board's  request  re- 
garding new  patients,  but,  although  repeatedly  invited  and 
urged  to  carry  out  the  arrangements  made,  he  failed  almost 
entirely  to  do  so,  and  brought  forward,  with  only  four  ex- 
ceptions— 

(a)  Cases  of  which  the  treatment  had  terminated. 

(b)  Cases  under  treatment  prior  to  the  opening  of  the  in- 
quiry. 

(c)  Cases  of  which  the  treatment  had  been  commenced  after 
the  inquiry  had  opened,  but  which  were  not  submitted  for  pre- 
liminary examination  as  had  been  arranged. 

"Mr.  Davis  also  wished  to  submit  for  investigation  cases 
which  he  admitted  were  not  cancer,  but  the  Board  could  not 
see  its  way  to  agree  to  this  course,  in  view  of  the  specific  terms 
of  its  appointment  and  of  the  inevitable  clouding  of  issues 
which  would  have  resulted  from  the  adoption  of  such  a  course." 

For  the  purpose  of  the  investigation,  it  was  considered  neces- 
sary for  the  Board  to  form  a  conception  of  the  essential  nature 
of  those  morbid  growths  which  are  classed  as  cancerous.  This 
having  been  done,  the  Board  proceeded  to  examine  46  wit- 
nesses, of  whom  32  had  been  or  then  were  patients  of  Mr. 


274  THE   CANCER   PROBLEM 

Davis.  Eleven  witnesses  were  medical  practitioners,  who  were 
examined  with  regard  to  fifteen  of  the  patients  whom  they 
had  formerly  seen  or  treated,  or  with  whom  they  had  been 
otherwise  professionally  connected. 

As  a  result  of  its  inquiries  and  investigations,  the  Board 
rendered  the  following  conclusions: 

^'1.  That  nothing  which  has  transpired  since  the  issue  of 
Progress  Keport  calls  for  the  cancellation  of  any  of  the  findings 
set  out  in  that  Report  (see  Appendix  "A"  to  this  Report). 

''2.  That  none  of  the  claims  made  to  the  Board  by  Mr.' 
Davis  has  any  foundation  in  fact. 

"3.  That  the  statement  that  the  substance  is  unique  or 
essentially  different  from  old  and  largely  discarded  caustic 
agents  is  incorrect. 

"4.  That  the  substance  used  by  Mr.  Davis  is  essentially  an 
arsenical  preparation. 

"5.  That  arsenic  is  a  well  and  long-known  escharotic  or 
destructive  agent,  destroying  any  live  tissue  with  which  it  is 
brought  into  intimate  contact.  It  does  not  exercise  any  marked 
selective  action,  that  is,  it  does  not  destroy  cancerous  tissue 
and  leave  healthy  tissue  unaffected. 

"6.  That  the  substance  used  by  Mr.  Davis  is  not  an  ef- 
fective means  for  the  treatment  of  cancer.  When  applied  for 
a  sufficient  length  of  time  to  any  portion  of  the  surface  of  the 
body,  it  acts  as  a  caustic  or  escharotic,  and  destroys  tissues, 
whether  healthy  or  diseased,  with  which  it  is  in  contact.  In 
this  way  a  small  superficial  growth  might  be  removed  by  the 
application  of  the  substance,  but  no  action  is  exercised  upon 
the  more  deeply-seated  cancerous  deposits  which  may  be  pres- 
ent, even  in  the  case  of  small  and  apparently  superficial 
growths. 

"The  simultaneous  complete  eradication,  not  only  of  the 
primary  superficial  growth,  but  of  the  secondary  deeper  de- 
posits, is  the  essential  feature  of  the  effective  treatment  of 
cancer. 

"7.  That  the  evidence  clearly  revealed  that  Mr.  Davis  is 
ignorant  of  the  essential  nature  and  evolution  of  the  disease 
which  he  claims  to  be  able  to  cure,  and  of  the  mode  of  its  ex- 
tension and  the  consequent  indications  for  treatment. 

''As  a  result  of  this  lack  of  knowledge,  wholly  unnecessary 
suffering  must  have  resulted  from  the  use  of  the  treatment 
after  the  disease  had  established  itself  in  other  parts  than  that 
first  attacked.  The  Board  saw  cases,  and  had  before  it  evi- 
dence of  other  cases,  in  which  this  had  occurred. 

''8.     That  no  case  unequivocally  diagnosed  (by  microscopi- 


THE    INVESTIGATION   OF   "CANCER   CURES"      275 

cal  examination)  as  cancer  by  the  medical  members  of  the 
Board  was  subsequently  produced  cured,  or  with  the  growth 
removed. 

"The  Board  is  of  the  opinion  that  public  safety  demands  a 
certain  degree  of  public  control  of  the  medical  treatment  by 
irregular  practitioners  of  cancerous  (malignant)  growths  and 
allied  diseases,  and  that  persons  suffering  from  such  diseases 
should  be  protected  in  some  measure  from  exploitation  by 
irregular  practitioners, 

"It  is  therefore  recommended  that  any  such  practitioners 
claiming  to  treat  cancer  and  allied  diseases  should  be  re- 
quired— 

"1.  To  notify  to  the  Department  of  Public  Health  his 
name  and  address  (also  any  change  of  address). 

"2.  To  lodge  with  the  Department  a  copy  (duly  sworn  to) 
of  the  formula  of  any  preparation  used  in  the  treatment,  to- 
gether with  certified  specimens  of  the  preparation  and  a  de- 
scription of  the  method  of  treatment. 

"3.  To  report  each  case  which  he  undertakes  to  treat  so 
that  an  investigation  could,  if  deemed  advisable,  be  carried 
out  by  competent  officers  commissioned  by  the  Department. 

"4.  To  forward  to  the  Department  copies  of  any  advertise- 
ments issued  in  respect  of  such  treatment. 

"If  these  recommendations  are  adopted,  it  is  considered  that 
in  the  necessary  legislation  provisions  should  be  made 

"1.  For  the  prohibition  of  objectionable  or  misleading 
advertisements  by  such  practitioners. 

"2.  For  the  restriction  of  practice  in  any  case  after  due 
inquiry. 

"3.  For  the  advertising  of  the  facts  in  any  case  of  restric- 
tion of  practice." 

The  evidence,  taken  in  shorthand,  is  published  in  appendices 
to  the  report. 

The  total  cost  of  investigation  was  123  pounds  16  s.  5  d. 

It  is  a  pity  that  other  countries  do  not  follow  these  examples 
of  legislative  investigation  of  an  alleged  cure  for  cancer  which 
is  in  opposition  to  the  known  facts  of  medical  science,  and  thus 
deprive  the  whole  criminal  brood  of  "cancer  quacks"  of  the 
liberty  of  treating  this  disease  by  means  of  secret  remedies. 
Such  investigation,  confined  within  the  ranks  of  the  medical 
profession,  may  easily  be  advertised  as  "persecution"  by  the 
particular  quacks  involved,  and  thus,  instead  of  ending,  may 
augment  the  evil.  A  committee  of  intelligent  la^Tnen  working 
with  physicians  in  the  taking  of  evidence  concerning  such 
"cures,"  many  dozens  of  which  are  daily  being  advertised  in 


276  THE  CANCER   PROBLEM 

the  public  press  in  this  coimtry  alone,  would  accomplish  much 
toward  their  complete  elimination. 

There  should  be  some  central  clearing-house  (such  as  is 
furnished  by  the  Imperial  Cancer  Research  Fund)  for  infor- 
mation concerning  all  such  methods  and  measures;  the  duty 
of  such  an  institution  or  body  being  to  enlighten  the  public, 
upon  request,  or  by  a  systematic  campaign  of  education  con- 
cerning the  criminal  frauds  being  perpetrated  against  this  most 
unfortunate  class  of  suiferers.  In  another  chapter  the  subject 
of  educating  the  public  with  reference  to  cancer  is  discussed 
more  fully. 

SUMMARY 

The  foregoing  review  of  some  typical  instances  of  the  more 
or  less  formal  investigation  of  cancer  "cures"  emphasizes  the 
possibility  for  harm  which  comes  with  the  premature  exploita- 
tion, in  the  medical  or  the  secular  press,  of  any  method  of  treat- 
ment. It  cannot  be  unqualifiedly  asserted  that  one  or  a  hun- 
dred cases  successfully  treated  by  a  given  method  establishes 
its  value  with  sufficient  positiveness  to  warrant  the  application 
of  such  a  method  to  the  exclusion  of  surgical  intervention.  A 
test  with  negative  findings,  on  the  other  hand,  if  fairly  con- 
ducted in  a  reasonably  large  number  of  cases,  may  be  said  to 
afford  ample  justification  for  the  abandonment  of  such  a  pro- 
cedure. 

The  study  of  the  many  agents  and  methods  which  have  been 
employed  in  the  treatment  of  cancer  leads  to  a  reiteration  of 
the  statement  that,  in  the  present  state  of  knowledge,  surgery 
offers  the  only  dependable  hope  of  cure.  Other  measures  may 
be  employed,  but  only  as  adjuvant  agents. 


SECTION    X 

NON-SURGICAL    TREATMENT 

CHAPTER   I 
CAUSTICS   OR   ESCHAROTICS 

It  has  ever  been  a  characteristic  of  human  psychology  to 
attempt  to  utilize  the  "elements"  in  the  treatment  of  human 
ailments.  Until  quite  recently,  when  the  imitation  or  reen- 
forcement  of  the  natural  processes  of  healing  became  possible, 
as  seen,  for  example,  in  the  case  of  diphtheria,  this  has  been 
the  natural  course  of  events  after  every  advance  in  physical  or 
chemical  knowledge.  The  direct  application  of  fire,  in  ancient 
times  in  the  treatment  of  the  ailments  of  man,  is  doubtless  the 
origin  of  the  present-day  custom  of  treating  horses  by  "firing." 
The  most  modern  illustration  of  this  resort  to  the  elements  is 
the  application  of  radium  to  cancer;  for,  however  rational  the 
use  of  this  power  may  become,  in  its  beginning  it  was  little 
more  than  primitive  empiricism. 

The  destruction  of  a  tumor  in  situ  has  always  been  the 
alternative  to  cutting  it  out,  and  in  all  probability  it  is  the 
older  of  the  two  proceedings.  The  means  of  destruction  that 
have  found  favor  from  one  age  to  another  have  varied  with  the 
knowledge  of  the  times.  The  red-hot  iron  was  no  doubt  the 
successor  of  the  red-hot  stone,  and  each  was  possibly  used 
with  the  idea  that,  while  sparing  other  parts,  it  would  exercise 
a  specific  action  upon  the  part  to  which  it  was  applied.  The 
wished-for  localized  action,  in  all  probability,  was  attained  in. 
so  far  as  immediate  results  were  concerned ;  and  in  early  times, 
when  the  patient  died — for  reasons  which  we  may  suppose  were 
various — death  was  probably  dissociated  from  the  crude  at- 
tempts at  treatment. 

The  mysticism  of  the  alchemists  was  associated,  not  only 
with  the  search  for  the  philosopher's  stone,  which  was  to  turn 
base  metals  into  gold,  but  also  with  the  pursuit  of  the  "elixir 
of  life"  and  a  "cure  all"  for  disease.     The  alchemist  found  his 

277 


278  THE  CANCER   PROBLEM 

medical  successor  in  the  apothecary,  with  his  vested  right  not 
only  in  the  compounding  of  medicines,  but,  in  England,  even 
in  the  power  to  grant  the  privilege  to  practice  medicine. 
Among  the  general  nm  of  people  this  traditional  authority  of 
the  apothecary  is  kept  alive  by  the  readiness  with  which  a 
druggist  is  often  consulted,  rather  than  a  member  of  the  medi- 
cal profession,  whenever  the  patient  has  a  pang  of  conscience 
aroused  by  the  symptoms  of  illness. 

In  other  respects  the  world  is  not  yet  entirely  free  from  the 
traditions  of  old.  Reputable  members  of  the  clergy  may  be 
found  who  still  maintain,  with  as  much  vehemence  as  in  the 
days  Vt^hcn  monasteries  abounded  and  each  had  its  garden  of 
healing  herbs,  the  traditional  claims  of  the  church  to  healing 
powers.  "Old  wives'  remedies,"  as  they  are  called,  still  have 
their  vogue,  and  the  herbalist  still  thrives  on  credulity  and 
ignorance. 

In  no  disease  is  this  more  true  than  in  cancer,  for,  in 
addition  to  "old  wives'  remedies"  and  "herbal  cures,"  ac- 
tual destruction  of  tissues  by  heat  (for  example,  hot  air 
under  pressure),  and  by  other  ancient  caustics,  such  as  ar- 
senic, chlorid  of  zinc,  sulphuric  and  nitric  acids,  still  find  ad- 
vocates. 

In  earlier  times,  it  must  be  admitted,  there  was  sound  ex- 
cuse for  seeking  an  alternative  to  the  knife,  whose  use  was  fre- 
quently followed  by  pyemia,  erysipelas,  and  excessive  or 
uncontrollable  loss  of  blood.  Applied  to  an  ulcerating  cancer, 
arsenical,  mercurial,  or  other  caustic  paste  did  not  cause  pyemia 
— it  was  an  unintentional  antiseptic  application — and  there- 
fore often  entailed  less  immediate  risk  than  the  use  of  the  knife. 
When  death  ensued  after  some  temporary  relief,  if  it  were  not 
due  to  the  advance  of  the  disease,  or  to  the  sudden  erosion,  by 
the  caustic,  of  a  blood  vessel,  knowledge  was  not  sufiiciently 
advanced  at  first  to  lay  the  blame  on  arsenical,  mercurial,  or 
other  poisoning,  which  later  came  to  be  recognized  as  its  cause. 
When  applied  to  tumors  covered  by  sound  skin,  such  caustic 
pastes  were  found  to  be  without  effect.  Therefore  the  skin 
was  destroyed  by  vitriol  or  cut  into,  and  daily  cuts  were  made 
deeper  and  ever  deeper  into  the  tumor  to  facilitate  penetration 
by  the  caustic.  Results  were  then  obtained  like  those  for  ulcer- 
ating tumors. 

In  this  way,  fostered  by  the  hope  which  was  father  to  the 
thought,  the  theory  was  possibly  built  up  that  caustics  exer- 
cise a  selective  action  upon  the  cancer  cells  while  sparing 
healthy  tissue.  This  theory  was  long  acted  upon,  in  all  good 
faith,  and  is  advocated  to-day  by  ethical  physicians  who  put 


CAUSTICS    OR    ESCHAROTICS  279 

forth  fresh  claims  to  cure  cancer  by  caustica  which  are  as- 
serted to  have  a  specific  action  on  cancer  cells. 

When  once  the  old  mineral  caustics,  such  as  arsenic,  tartar 
emetic,  and  chlorid  of  zinc,  were  found  not  to  have  a  specific 
action  and  to  be  dangerous  to  health  when  absorbed,  it  was  but 
natural  that  others  of  less  easily  definable  constitution,  and 
supposed  to  be  less  harmful,  should  be  employed.  Thus  it 
came  about  that  sulphuric  and  nitric  acids  were  introduced, 
with  the  necessary  additional  precautions,  as  were  likewise 
acetic  and  chromic  acids. 

Many  escharotic  vegetable  juices,  such  as  that  of  euphorbia, 
also  acquired  prominence.  Among  more  recent  examples  may 
be  mentioned  jequirity,  which  is  an  active  vegetable  irritant 
and  protoplasmic  poison.  The  older  traditions  are  maintained 
by  formic  acid,  formalin,  and  potassium  bichromate,  all  three 
of  which  are  interesting,  if  only  for  the  reason  that  they  are 
used  by  histologists  to  harden  normal  and  pathological  tissues, 
including  cancer,  for  the  purpose  of  preparing  them  for  micro- 
scopical study.  Inserted  into  the  body,  their  immediate  or 
direct  action  is  not  restricted  to  the  tumor  tissue,  but  extends 
to  all  the  tissues  with  which  they  come  in  contact.  They  may 
have  remote  effects  on  other  organs  like  those  which  result  in 
chronic  arsenical  or  mercurial  poisoning,  particularly  if  they 
lead  to  blood  destruction  or  to  damage  to  the  kidneys.  They 
are  dangerous  drugs,  not  prescribed  in  any  circumstance  what- 
soever in  doses  exercising  so  much  of  their  poisonous  effects 
as  would  be  produced  by  absorption  when  employed  in  the  way 
they  are  recommended  for  cancer. 

The  emplojinent  of  caustics  has  become  ever  and  ever  more 
limited.  There  was  a  time  when,  although  they  were  no 
longer  advocated  as  cures,  they  were  still  applied  during  the 
waiting  stage,  during  the  "precancerous"  period,  when  an 
ulcer,  for  example,  of  the  tongue,  was  being  watched  to  see  if 
cancer  would  develop.  The  disastrous  consequences  of  this 
"waiting"  have  been  well  emphasized  by  Butlin.  (See  Sec- 
tion V,  p.  133.)  To-day  the  practice  is  abandoned,  except 
among  a  few  who  use  mild  caustics  like  alum  or  silver  nitrate 
upon  ulcers  in  the  early  stage  of  the  precancerous  period.  This 
only  serves  to  invite,  by  irritation,  a  malignant  process.  Thus 
a  modern  physician  or  surgeon  is  not  an  unbiased  critic  of  the 
method,  which  may  be  more  fittingly  set  forth  in  the  words  of 
one  who  gave  it  an  impartial  trial  in  the  days  when  it  was  still 
in  vogue,  before  surgery  had  attained  to  anything  like  its 
present  development.  This  purpose  is  fulfilled  by  the  descrip- 
tion of  C.  H.  Moore,  of  the  Middlesex  Hospital,  London, 


280  THE   CANCER   PROBLEM 

In  1870,  in  the  second  edition  of  Holmes'  System  of  Sur- 
gery,^ Moore  was  associated  with  Sir  James  Paget  in  the 
articles  on  cancer.  Regarding  treatment  by  caustics,  Moore 
wrote : 

"By  means  of  caustics  efficiently  used,  it  is  possible  to  destroy 
the  vitality  of  a  whole  tumour  and  obtain  its  complete  re- 
moval ;  but  the  pain  ordinarily  occasioned  by  them  forbids  their 
employment  when  chloroform  and  the  knife  are  not  contra- 
indicated.  Caustics  exert  no  especially  curative  action  upon 
cancer  structures,  but  they  present  two  advantages  over  a  cut- 
ting operation.  Their  employment  is  not  attended  by  an 
effusion  of  blood  and  the  consequent  exhaustion,  or  by  erysipe- 
las or  pyemia.  And,  further,  in  most  cases  they  occasion  a 
considerable  emaciation  of  the  healthy  tissues  adjoining  the 
slough,  and  a  diminution  in  the  size  of  glands  secondarily 
affected  with  cancer.  Among  many  patients  treated  in  the 
Middlesex  Hospital  with  caustics  in  the  summer  of  1857,  there 
was  a  marked  difference  in  the  effects.  In  some  it  appeared 
to  act  in  the  same  manner  as  erysipelas  and  hospital  gangrene. 
Apparently,  but  in  fact  incompletely,  removed,  the  disease  re- 
appeared in  a  few  weeks;  in  those  cases,  however,  in  which 
caustics  were  carried  through  the  cancer  into  healthy  tissues 
no  such  recurrence  took  place  before  the  healing  of  the  wound. 
After  that  event,  the  cases  treated  by  caustics  followed  the 
ordinary  course  of  cancer.  Disease  reappeared,  and  death 
ensued  as  usual. 

"l^one  of  these  results  of  the  use  of  caustics  differ  materially 
from  those  which  attended  a  cutting  operation,  and  in  cases 
which  are  equally  adapted  for  either,  British  surgeons  do  not 
resort  to  caustics.  There  are  some  instances  of  advanced  and 
ulcerated  cancer,  however,  attended  with  suffering,  but  having 
adhesions  which  could  not  be  detached  with  the  knife;  and  m 
these  a  gradual  insertion  of  caustic  is  sometimes  followed  by 
the  complete  enucleation  of  the  tumour  and  cicatrisation  of  the 
wound.  In  a  case  of  medullary  cancer  of  the  parotid  region, 
of  very  rapid  growth,  and  so  full  of  blood  vessels  as  to  pulsate 
and  bleed  severely,  the  writer  first  tied  the  carotid  artery,  and 
then  employed  the  caustic  paste.  The  comfort  and  prolonga- 
tion of  life  resulting  from  such  treatment  reconcile  the  patient 
to  the  temporary  pain  by  which  those  advantages  are  gained. 

"If,  on  such  grounds  as  the  less  probability  of  a  fatal  result 
from  the  mode  of  proceeding,  it  be  determined  to  treat  a  pri- 

1  Moore,  C.  H.,  in  "  A  System  of  Surgery,  Theoretical  and  Practical,  in 
Treatises  by  Various  Authors, ' '  edited  by  T.  Holmes.  2nd  ed.  Vol.  I,  Gen- 
eral Pathology.     London,   1870,  p.  605. 


CAUSTICS    OR    ESCHAROTICS  281 

mary  cancer  with  caustics,  the  general  rules  must  be  observed 
which  are  applicable  to  the  selection  of  cases  for  a  cutting 
operation.  The  tumour  must  be  primary,  solitary,  and  uncom- 
plicated with  evident  constitutional  disease  or  infection  of  the 
parts  around  it.  Should  the  absorbent  glands  be  affected,  the 
operation  by  the  knife  is  decidedly  preferable  to  that  by  caus- 
tics, as  it  is  difficult  to  remove  glands  by  the  latter  method. 

"There  are  various  methods  of  cauterizing  a  cancerous  tu- 
mour. If  a  liquid  be  chosen,  its  application  must  be  limited  by 
some  contrivance ;  as,  for  example,  a  hoop  or  cylindrical  tube 
of  gutta-percha,  set  on  its  edge  around  the  tumour,  and  closely 
glued  to  the  skin  by  means  of  a  solution  of  the  same  material 
in  chloroform.  The  caustic  liquid,  poured  into  the  cup  thus 
formed,  or  laid  in  it  as  a  paste  made  with  saffron  or  sawdust, 
will  then  burn  through  the  diseased  mass,  the  depth  of  its 
action  being  determined  beforehand  by  the  quantity  of  the 
caustic  employed.  The  strong  sulphuric  acid  and  the  fuming 
nitric  acid  produce  a  dry,  hard,  and  much-concentrated  eschar, 
which  separates  spontaneously  in  the  course  of  from  one  to  four 
weeks,  and  leaves  a  granulating  and  cicatrising  sore. 

"Chloride  of  zinc  may  be  made  into  a  cake  or  a  paste  with 
flour,  or  may  be  employed  alone.  It  can  only  be  used  upon  a 
denuded  surface.  If  the  skin  is  entire,  it  must  be  first  blistered 
or  killed  with  the  concentrated  nitric  or  sulphuric  acid.  The 
chloride  may  then  be  laid  over  the  tumour  and  allowed  to  pene- 
trate through  it.  When  the  cancer  is  already  ulcerated,  the 
zinc-paste,  diluted  for  the  first  application,  may  be  soaked 
through  cotton-wool  and  introduced  into  the  ulcer.  The  caustic, 
infiltrating  the  tissues,  coagulates  their  albumen  and  blood, 
and  produces  a  slough,  which  is  friable,  inodorous,  and  less- 
dry  than  that  resulting  from  the  acids,  but  which  separates  in 
the  same  manner. 

"When  white  arsenic  was  employed,  it  was  mixed  with  cal- 
omel, or  bichloride  of  mercury,  or  merely  with  flour,  and  laid  in 
very  small  quantity  upon  a  raw  surface  over  the  cancer.  Like 
the  chloride  of  zinc,  it  is  inert  if  applied  to  the  skin.  A  very 
small  quantity,  not  more  than  two  or  three  grains  of  this 
caustic,  was  used  at  a  time;  but  as  it  became  absorbed,  and 
some  patients  died  in  consequence,  the  use  of  it  has  been  aban- 
doned. 

"A  convenient  plan  for  extirpating  a  cancerous  tumour,  and 
one  which  keeps  the  action  of  the  caustic  within  the  control  of 
the  surgeon,  is  to  lay  the  paste  of  the  chloride  of  zinc  within  a 
cancerous  ulcer,  or  on  skin  previously  destroyed  by  a  strong 
acid,  in  the  manner  already  described,  and,  through  incisions 


282  THE   CANCER   PROBLEM 

deepened  daily  as  the  slough  extends,  to  introduce  fresh  quanti- 
ties of  the  same  caustic,  until  the  whole  tumour  is  perforated 
and  destroyed.  It  is  then  east  off,  and  a  healing  wound  occu- 
pies its  place.  The  process  is  a  slow  one,  and  portions  of  the 
tumour  are  apt  to  be  left  behind  and  to  require  a  renewal  of  the 
treatment.  It  is  also  sometimes  incapable  of  overtaking  the 
progress  of  a  very  rapidly  growing  cancer.  But  it  is  ordinarily 
less  painful  than  any  other  cauterization,  and  is  applicable  in 
some  cases  in  which  a  tumour  is  so  situated  that  the  knife  could 
not  be  used.  Thus  the  effective  part  of  the  treatment  intro- 
duced into  England  by  Dr.  Fell,  of  the  United  States,  was 
described  at  length,  and  an  estimate  of  its  surgical  value  of- 
fered, in  a  Report  on  the  Treatment  of  Cancer  in  the  Middle- 
sex Hospital  in  1857.  In  making  the  paste  it  is  desirable  to 
use  a  saturated  solution  of  the  chloride  of  zinc. 

"Mr.  Shaw  has  favoured  me  with  the  following  interesting 
memorandum : 

"  'Mr.  Whitbread  introduced  to  Sir  C.  Bell  a  Dr.  Chuna, 
son  of  a  physician  at  Lisbon,  and  who  treated  cancer  of  the  face 
with  a  powder  called  by  his  name.  It  was  made  up  of  one  part 
of  tartar  emetic  and  two  of  sulphate  of  zinc.  It  was  used  by 
scarifying  along  the  outer  edge  of  the  ulcer,  and  filling  the  cut 
with  the  powder.  It  raised  a  great  inflammation,  on  the  sub- 
sidence of  which  the  spreading  ceased.  I  remember  Sir  C.  Bell 
employing  it  in  a  rather  elderly  male  hospital  patient.  The 
only  effect  I  can  recall  is  that  great  tumefaction  and  exceedingly 
severe  pain  followed,  and  that  the  results  deterred  Sir  Charles 
from  using  it  in  any  other  case.' 

"The  hypodermic  injection  apparatus  has  been  used  by  Sir 
J.  Y.  Simpson  for  the  purpose  of  injecting  into  tumours  caus- 
tics in  a  liquid  form,  and  by  means  of  it  he  succeeded  in  de- 
stroying a  fatty  tumour.  The  same  apparatus,  employed  inde- 
pendently by  Dr.  Broadbent,  furnished  the  means  of  introduc- 
ing solvents  into  the  substance  of  cancers,  and  he  has  actually 
succeeded  in  dissolving  away  tumours  of  that  nature  in  the  liv- 
ing body.  He  selected  the  acetic  acid  for  its  known  chemical 
effects  on  cancers  under  the  microscope,  and  diluted  it  with 
three  times  its  bulk  of  water.  The  injection  of  a  few  minims 
or  a  drachm  into  a  cancerous  tumour  is  immediately  painful, 
but  if  any  escape  into  the  adjoining  textures,  the  smarting  is 
severe.  After  a  temporary  redness  and  swelling,  the  tumour  is 
found  smaller,  and  it  may  eventually  disappear.  By  a  single 
injection  Mr.  De  Morgan  and  I  have  each  succeeded  in  obtain- 
ing such  gradual  diminution  of  cancerous  tumours,  which  have 
not  reappeared  for  two  years  and  a  half.     That  this  remedy 


CAUSTICS    OR    ESCHAROTICS  283 

acts  as  a  chemical  solvent  of  the  cell  was  shown  by  a  specimen 
which  I  exhibited  at  the  Pathological  Society  of  London. 
(Transactions,  Vol.  XVIII,  p.  236.)" 

Since  Moore's  observations  were  published,  44  years  have 
elapsed.  Experience  with  the  caustic  treatment  of  cancer,  ac- 
cumulated in  the  interval,  more  than  justifies  his  judicious 
reluctance  to  resort  to  the  method,  more  especially  in  the  light 
of  the  advances  of  surgical  technic  which  he  advocated  but  did 
not  live  to  see  carried  out.  The  caustics  he  mentioned  are 
even  now  occasionally  heard  of  in  ethical  practice;  they  are 
still  the  common  stock  of  the  quack. 

In  professional  practice  arsenic  has  changed  its  form  into 
atoxyl  and  salvarsan;  acetic  acid  appears  in  the  form  of  its 
near  chemical  relatives,  formic  acid  and  formalin,  and  chromic 
acid  is  now  known  as  potassium  bichromate.  On  more  rational 
grounds  we  have  newer  destructives  of  rapidly  growing  tissue 
in  X-rays,  radium,  and  mesothorium.  These  will  be  considered 
separately  Vide  infra.  Chapter  II),  not  only  for  the  reason 
that  they  maintain  the  continuity  of  mankind's  search  for  a  ra- 
tional substitute  for  the  knife  as  a  cure  for  cancer,  but  also 
because  at  present  their  use  appears  more  rational  than  the 
indiscriminately  destructive  caustics  of  old. 

The  list  of  "useful"  caustics  has  been  reduced  by  some  advo- 
cates of  this  method  to  five,  viz. :  potassa  fusa  (caustic  potash)  ; 
zinc  chlorid;  strong  sulphuric  acid;  iron  chlorid;  arsenic.  Of 
these,  zinc  chlorid  and  arsenic,  in  various  pastes  and  other 
combinations,  have  been  most  extensively  used. 

Zinc  chlorid,  in  one  form  or  another,  has  been  more  widely 
employed  perhaps  than  any  other  caustic  agent.  With  the  ad- 
dition of  this  or  that  agent,  it  has  been  exploited  as  a  "new 
cure"  from  time  to  time  for  many  years. 

Probably  one  of  the  most  conspicuous  examples  was  the  "Dr. 
Fell  Treatment,"  tested  by  the  Middlesex  Hospital  in  1857, 
already  mentioned.  In  this  instance  zinc  chlorid  was  mixed 
into  a  glutinous  paste,  which,  in  advanced  cases,  was  applied 
directly  to  ulcerated  surfaces,  or,  in  cases  in  which  the  skin 
over  the  tumor  remained  unbroken,  to  the  tissues  exposed  by 
means  of  "progressive  incisions." 

Canquoins  paste,  consisting  of  zinc  chlorid  and  flour,  is  one 
of  the  most  widely  used  forms  of  this  escharotic  agent. 

Bougard's  paste  has  for  one  of  its  chief  ingredients  zinc 
chlorid. 

Zinc  chlorid  solution,  30  to  50  per  cent.,  was  more  exten- 
sively used  by  the  late  J.  Marion  Sims  than  any  other  form  of 


284  THE   CANCER    PROBLEM 

treatment.  He  applied  it,  on  pledgets  of  absorbent  cotton,  in 
the  hole  made  bj  the  curet. 

Zinc  chlorid  solution,  5  per  cent.,  has  been  used  for  paren- 
chymatous injection. 

It  has  been  maintained  by  some  writers  that  zinc  chlorid 
destroys  only  cancerous  structures;  others  who  have  carefully 
experimented  with  the  agent  do  not  accept  this  view. 

Arsenic . and  its  derivatives,  as  remedies  in  the  treatment  of 
various  diseases  of  the  skin,  received  mention  from  the  earlier 
medical  writers.  Fuchs,  in  1594,  employed  it  externally  in  the 
treatment  of  cancer.  It  was  not,  however,  until  the  early  part 
of  the  nineteenth  century  that  it  became  a  recognized  agent  in 
the  treatment  of  malig-nant  diseases.  Its  use,  in  various  forms — 
powder,  paste,  solution,  etc. — was  extended  after  this,  until  it 
finally  came  to  play  a  conspicuous  part  in  the  treatment  of  can- 
cer. It  forms  the  chief  ingredient  of  many  of  the  pastes  and 
plasters  employed  at  the  present  time  by  some  of  the  ethical  as 
well  as  the  unethical  members  of  the  medical  profession. 

Interest  in  arsenic,  in  the  treatment  of  malignant  disease, 
was  given  an  impetus  in  1897,  when  Cerny  and  Trunecek  re- 
ported their  experience  with  a  hydro-alcoholic  solution  of 
arsenic  acid.-'  The  method  found  many  adherents  for  a  time, 
and  is  still  used  to  some  extent. 

Manecs  paste  consists  of  arsenic,  cinnabar,  and  burnt  spurge. 

Marsden's  paste  contains  arsenious  acid  and  powdered 
acacia. 

Bougard's  paste,  previously  mentioned,  contains  arsenic. 

Parenchymatous  injectio7is  of  arsenious  acid  have  been  tried 
by  a  number  of  investigators.  A  few  have  recorded  favorable 
results,  while  others  have  reported  the  contrary. 

"Arphoaline"  a  combination  of  arsenic  with  phosphorus  in 
albumin,  employed  internally  and  by  local  application,  has  re- 
ceived a  limited  degree  of  attention. 

In  addition  to  zinc  chlorid,  and  arsenic  and  its  derivatives, 
many  other  agents  have  been  employed  for  their  caustic  prop- 
erties. Among  these  may  be  mentioned:  acetic  acid  (injected 
into  growth)  ;  bromin  (painted  around  cancer)  ;  carbolic  acid 
(injection) — dangerous;  chromic  acid  (potassium  bichrom- 
ate); formic  acid  (formalin) — probably  dangerous;  nitric 
acid;  papain  as  injection;  pepsin;  perchlorid  of  iron;  potassa 
fusa    (caustic  potash)  ;    sulphuric   acid    (with  half  of  lime — ■ 

1  Cerny  and  Trunecek. — ' '  Guerison  radicale  du  cancer  epitheliale, ' '  Se- 
maine  medicale,  May,  1897,  XVII,  p.  161.  See  also:  Vignat,  Marcel. — 
"Contribution  a  I'etude  de  la  Metliode  de  Cerny  et  Trunecek,"  These  de 
Paris,   1900. 


CAUSTICS    OR    ESCHAROTICS  285 

Vienna  paste);  tartar  emetic;  terchlorid  of  antimony;  zinc 
sulphate;  chlorid  of  gold;  thoremiden,  or  thorium  paste  (Sem- 
erak).  Many  others,  particularly  mild  caustics  of  vegetable 
origin,  have  been  utilized.  In  many  of  the  so-called  cancer 
cures  the  juices  of  the  various  plants  of  the  EupJiorhia  family, 
and  also  jequirity,  have  been  used,  generally  in  connection 
with  other  substances. 

The  advocacy  of  caustics  by  ethical  practitioners  of  the  pres- 
ent day  is  presumably  based,  as  Park  ^  has  pointed  out,  upon 
the  assumption  that  the  resulting  reaction  tends  to  block  lymph 
channels,  and,  in  consequence  of  the  violent  and  extensive 
reaction,  to  produce  "a  sanitary  cordon  of  fresh  inflammatory 
tissue  which  walls  off  the  area  of  pathologic  activity  and  may 
also  destroy  scattered  cancer  cells."  Still  it  is  doubted  if  any 
such  eifective  cordon  is  produced,  because  the  caustic  action  is 
not  limited  to  the  cancer. 

In  epithelioma  of  the  skin,  aside  from  cases  which  demand 
extirpation  of  contiguous  lymph  glands  at  the  time  of  removal 
of  the  growth,  excision,  according  to  Pusey,^  is  not  as  good  a 
method  as  the  application  of  X-rays  or  caustics.  The  objection 
to  excision,  he  says,  is  "that  the  outlying  radicals  of  the  tumor 
extend  well  beyond  the  apparent  border  of  the  growth,  and 
their  removal  by  excision  requires  the  sacrifice  of  a  great 
amount  of  healthy  tissue.  The  deformity  which  results  is 
therefore  great.  But  a  more  important  objection  is  that  even 
the  most  careful  surgeon  is  apt  to  fail  to  get  all  traces  of  the 
growth,  so  that  recurrence  is  common." 

Few  surgeons  would  accept  these  objections.  The  selective 
action  of  caustics  has  not  been  sufficiently  well  demonstrated 
to  warrant  the  belief  of  some  dermatologists  that  any  such 
agent  is  to  be  relied  upon  to  search  for  and  destroy  outlying 
radicals  which  cannot  be  found  by  the  surgeon.  It  is  safe  to 
say  that,  if  these  radicals  extend  far  enough  beyond  the 
"apparent  border"  of  the  growth  to  require  the  sacrifice  of  a 
great  amount  of  "healthy  tissue"  in  order  to  remove  them  by 
excision,  the  supposedly  healthy  tissue  is  doubtfully  so,  and 
should  be  removed  to  insure  against  recurrence.  The  objection 
with  reference  to  deformity  is  usually  easily  overcome  by  skin 
grafting  or  plastic  surgery.  The  last  objection,  with  reference 
to  failure  to  get  all  traces  of  the  growth,  involves,  again,  the 

iPark,  Eoswell  E. — "Recent  Views  Concerning  the  Treatment  of  Can- 
cer, Based  upon  Its  Nature,"  Buffalo  Med.  Jour.,  April,  1911,  p.  465. 

2Pusey,  William  Allen. — "The  Principles  and  Practice  of  Dermatol- 
ogy," 1911,  pp.  912-13. 


286  THE   CANCER    PROBLEM 

selective  action  of  the  caustic  agent,  which  is  always  a  debat- 
able factor. 

The  difference  of  opinion  among  dermatologists  and  sur- 
geons is  accounted  for  by  8tclwagon  ^  by  the  fact  that  the  cases 
coming  under  the  observation  of  the  dermatologist  are  rela- 
tively superficial  and  slight,  circumscribed  and  slow,  whereas 
those  coming  under  the  care  of  the  surgeon  are  of  more  serious 
nature.  Certainly  the  former  class  includes  the  only  cases,  to 
my  mind,  in  which  there  is  any  excuse  for  the  use  of  caustics, 
with  the  exception,  of  course,  of  cases  in  which  surgical  re- 
moval is  absolutely  refused. 

The  cases  usually  seen  by  the  dermatologist,  and  often  re- 
ported as  successfully  treated  by  curet  or  caustic,  are  of  squam- 
ous cell  epithelioma,  relatively  non-malignant,  and  are  not  to  be 
considered  when  describing  real  malignancy — true  cancer. 

Of  the  large  number  of  chemical  agents  which  have  been 
applied  to  cancer,  it  is  safe  to  state  that  in  the  majority,  if  not 
in  all  instances,  whatever  beneficial  effect  is  exerted  is  due  to 
the  caustic  action  of  the  agent  itself  or  of  some  ingredient 
employed  in  its  preparation  for  use  in  the  treatment  of  cancer. 

A  number  of  agents,  notably  cholin,  colloidal  copper,  and  selen- 
ium, have  recently  been  proposed  for  the  treatment  of  cancer, 
alone  or  in  conjunction  with  X-rays  or  radioactive  substances, 
but  no  convincing  reports  of  their  curative  efficacy  have  yet 
appeared.  For  this  reason  space  need  not  be  used  for  the  details 
concerning  them. 

SUMMARY 

The  extensive  studies  that  have  been  made  to  determine  the 
factors  which  predispose  to  the  development  of  cancer  have  given 
a  place  of  great  importance  to  irritation.  The  therapeutic  out- 
come of  such  conclusions  is  that  treatment  should  be  sedative 
rather  than  irritative.  Sedation,  and  not  irritation,  is  the 
watchword  wherever  cancer  has  been,  or  is  likely  to  be,  present. 

This  being  true,  caustics  have  practically  no  place  in  the 
treatment  of  malignant  disease  where  there  is  hope  of  cure ;  cer- 
tainly not  in  other  cases  than  those  which  are  known  to  be  super- 
ficial, slight,  circumscribed,  and  of  slow  growth.  Even  the  most 
expert  diagnostician,  however,  may  be  unable,  at  times,  to  make 
this  differentiation.  Furthermore,  it  is  to  be  remembered  that 
a  growth  may  be  small,  apparently  slight  and  circumscribed, 
and  yet  be  very  virulent  in  that  it  possesses  great  power  for  the 
formation  of  metastasis.  Unless  a  caustic  destroys  every  vestige 
of  malignancy,  in  such  a  case,  before  metastasis  has  occurred, 
its  use  merely  augments  the  danger. 

iStelwagon,  Henry  W. — "Diseases  of  the  Skin,"  1914,  p.  885. 


CHAPTER    II 
PHYSIOTHERAPY 

HEAT,  LIGHT,  ELECTRICITY,   RADIO-ACTIVITY 

In  1792  George  Adams,  Mathematical  Instrument  Maker  to 
His  Majesty,  and  Optician  to  His  Royal  Highness  the  Prince  of 
Wales,  reproached  the  medical  profession  for  lack  of  tenacity 
of  purpose  in  its  use  of  electricity,  at  the  same  time  forecast- 
ing the  history  of  electrotherapy  as  applied  to  cancer  at  the 
present  time.  In  his  book  on  electricity  *  he  says :  "The 
science  of  medicine  and  its  practitioners  have  been  reproached 
with  the  instability  and  fluctuations  of  practice;  at  one  time 
cold  as  the  ice  at  Zembla,  at  another  hot  as  the  Torrid  Zone; 
that  they  are  led  by  fashion  and  influenced  by  prejudice.  On 
this  ground  it  has  been  predicted  that,  however  great  the  bene- 
fits which  may  be  derived  from  electricity,  it  would  still  only 
last  for  the  day  of  fashion,  and  then  be  consigned  to  oblivion." 

Adams  declared  that  electricity  had  "considerable  scope  for 
action"  in  surgery;  tumors,  particularly  of  the  glandular  sort, 
being  included  in  the  catalogue  of  "visible  diseases  as  dis- 
tressing to  the  sight  of  others  as  to  the  patients  themselves," 
which  might  be  benefited  by  this  agent. 

On  glancing  over  the  voluminous  but  inconclusive  literature 
of  the  electrotherapeutic  treatment  of  cancer,  the  prophetic  in- 
sight of  this  early  observer  is  borne  out  nearly  two  hundred 
years  later.  What  applies  to  electrotherapy  is  equally  true  of 
its  concomitants,  phototherapy  and  radiotherapy. 

HEAT 

Heat,  per  se,  seems  to  have  received  little  attention.  Its 
therapeutic  value  in  the  treatment  of  cancer  has  not  been  en- 

1  Adams,  George. — ' '  An  Essay  on  Electricity,  Explaining  the  Principles 
of  that  Useful  Science;  and  describing  the  Instruments  Contrived  either  to 
illustrate  the  theory,  or  render  the  Practice  entertaining,  etc."  4th  edi- 
tion, 1792,  p.  494. 

287 


288  THE   CANCER   PROBLEM 

tirelv  dissociated  from  the  action  of  light  and  electricity,  except 
as  it  has  been  applied,  by  one  means  or  another,  for  the  relief 
of  pain  and  other  s^Tnptoms,  or  for  a  purely  cauterant  effect. 
It  will  therefore  not  receive  separate  consideration  here.  Its 
presumptive  causative  role  in  the  production  of  cancer  is  gen- 
erally attributed  to  the  factor  of  chronic  irritation,  as  seen  in 
the  natives  of  Kashmir,  who  use  the  Kangri  basket  (see  p.  67). 


LIGHT 

The  therapeutic  value  of  light  has  been  recognized  for  cen- 
turies, yet  it  is  only  within  recent  years  that  the  sunbaths  of 
China,  Japan,  Africa,  and  other  countries,  the  "heliosis"  of 
the  ancient  Greeks  and  Romans,  have  undergone  a  recrudes- 
cence and  a  metamorphosis  into  modern  solartherapy,  photo- 
therapy, and  actinotherapy,  and  have  come  to  be  applied  in  the 
treatment  of  malignant  neoplasms. 

SUNLIGHT 

The  literature  which  deals  with  the  various  methods  of  treat- 
ing cancer  contains  very  little  definite  information  concerning 
the  effect  of  sunlight  upon  this  disease.  Widmer  ^  reports  the 
cure  of  a  case  of  carcinoma  by  repeated  exposure  to  the  direct 
rays  of  the  sun.  Bie  ^  reported  seven  out  of  sixteen  cases  of 
epithelioma  cured  by  "concentrated  light."  The  diagnosis  in 
each  of  Bie's  cases  was  verified  by  microscopic  sections,  and 
the  patients  remained  free  from  the  disease  for  from  six 
months  to  two  and  a  half  years.  Thayer  ^  was  led  by  accident 
to  the  use  of  the  sun's  rays  in  the  treatment  of  cancer  and  other 
affections  of  the  skin,  employing  first  a  small  lens  (sun-glass), 
then  larger  and  more  perfect  lenses.  During  a  practice  of 
more  than  forty  years  he  claimed  to  have  used  no  remedy 
which  compared  with  solar  heat  in  its  curative  power.  In  the 
treatment  of  malignant  diseases,  he  said,  the  tissues  must  be 
fully  destroyed  or  carbonized. 

1  Widmer,  C. — '  *  Heilung  eines  Karzinoms  durch  Sonnenlicht  nebst 
einigen  Beitragen  zur  unmittelbaren  Liehttherapie, ' '  Miinch.  med.  Woch., 
1907,  liv,  619. 

2  Bie,  V. — ' '  Behandlung  von  Hautepitheliomen  mit  concentrirten  Licht, ' ' 
Dermat.  Zeitschr.,  Berl.,  1900,  VII,  630-41. 

3  Thayer,  O.  V. — "Concentrated  Rays  of  the  Sun  (Solar  Cautery)  as  a 
Eemedial  Agent,"  Pacific  Med.  Jour.,  San  Francisco  (1893),  XXXVI,  412- 
419.  Also  South.  Tract.,  Nashville,  1893,  XV,  360-367.  Also:  "The 
Treatment  of  Cancer,  Lupus,  and  Other  Malignant  Growths,  with  Concen- 
trated Sun's  Rays — Solar  Cautery,"  Pacific  Med.  Jour.,  1902,   XLV,   193. 


PHYSIOTHERAPY  28^ 

This  method  of  treatment,  according  to  Thayer,  was  at- 
tended with  little  pain  and  inconvenience,  no  general  or  local 
anesthetic  being  necessary.  Only  slight  reaction  and  pain  fol- 
lowed the  application  of  the  rays.  The  wounds  healed  sooner 
than  after  X-rays.  Not  more  than  twenty  or  thirty  treatments 
were  necessary,  and,  in  the  majority  of  cases,  not  more  than 
ten. 

Exposure  to  strong  sunlight,  by  promoting  circulation 
through  the  affected  areas,  in  some  cases  relieves  the  pain 
caused  by  nerve-pressure.  Just  what  part  the  heat-waves  play, 
aside  from  their  association  with  the  luminous  rays,  cannot  be 
stated. 

The  actinic  rays  of  the  sun  are  thought  to  play  little  or  no 
part  in  whatever  action  solartherapy,  by  means  of  the  sun- 
bath,  may  have  upon  cancer;  for,  as  Finsen  has  shown, ^  the 
blood  acts  as  a  barrier  to  the  passage  of  these  rays  through  the 
tissues,  necessitating  the  preliminary  more  or  less  complete 
exsanguination  of  the  part  to  be  treated. 

The  therapeutic  application  of  concentrated  sunlight  was 
formerly  made  by  means  of  various  lenses,  "sun-glasses,"  or 
"burning  glasses."  Finsen  devised  a  concentrating  apparatus 
which  not  only  gave  a  convenient  means  of  applying  the  rays, 
but  which  enabled  him  to  filter  out  the  calorific  and  luminous 
rays.  The  uncertainty  of  the  sunlight  led  to  the  almost  com- 
plete abandonment  of  this  method  in  favor  of  artificially  pro- 
duced light. 

Seelye  ^  has  recently  reported  the  successful  use  of  concen- 
trated sunlight  in  the  treatment  of  superficial  epitheliomata 
and  malignant  ulcers. 

ELECTRICITY 

ARC  LIGHT 

Finsen  inaugurated  the  scientific  treatment  of  disease  by  the 
application  of  light,  and  his  Light  Institute,  at  Copenhagen, 
has  been  the  Mecca  for  students  of  light-therapy.  Finding  the 
electric  arc  light  to  be  richer  in  ultra-violet  rays  than  sunlight, 
he  devised  large  arc  lamps,  the  rays  being  focused  by  quartz 
lenses  cooled  by  a  stream  of  water.  This  original  Finsen  lamp 
has  undergone  various  modifications,  looking  to  utility  and 
portability.     There  are  now  to  be  found  numerous  solar  arc 

1  See  Bie,  V. — ' '  Eemarks  on  Finsen 's  Phototherapy, ' '  Brit.  Med.  Jour., 
1899,  Vol.  2,  p.  825. 

2  Seelye,  Hiram  H. — ' '  Cutaneous  Epithelioma  Cured  by  Sunlight, ' '  New 
York  Med.   Jour.,  February   7,   1914,  p.   279. 


290  THE   CANCER   PROBLEM 

lights,  amouc;  which  may  be  mentioned  the  Finsen,  the  Finsen- 
Ixeyn,  the  (|}uartz  Mercury  Vapor  lamp,  and  the  Kromeyer 
lamp. 

The  arc  light  has  been  successfully  employed  by  Finsen/ 
Petersen,-  Burgsdorf,^  and  others,  in  the  treatment  of  epithe- 
lioma during  the  early  stages.  It  has  not  been  used  for  car- 
cinoma when  not  situated  on  the  surface  of  the  body,  or  for 
sarcoma,  and  has  been  practically  abandoned  even  in  the  cases 
of  superficial  epitheliomata. 

As  a  purely  palliative  measure  the  arc  light  in  its  various 
forms  has  been  employed  by  a  number  of  investigators. 

The  study  of  the  action  of  light  on  the  lower  forms  of  both 
vegetable  and  animal  life,  in  Hyde's  ^  opinion,  points  to  the 
probability  that  in  man  exposure  to  actinic  rays  produces  a 
perceptible  stimulation  of  the  skin ;  and  that  this  stimulation 
is  effective  in  proportion  to  the  special  irritability  of  the  in- 
tegument on  which  it  falls, 

''It  is  important,"  he  says,  "to  recognize  the  connecting 
links  in  this  chain  of  events  associated  with  all  radioactive 
phenomena,  for  the  reason  that,  in  the  case  of  the  rays  most 
carefully  studied,  therapeutical  are  intimately  bound  up  with 
pathological  results.  Thus  the  action  of  the  Finsen  light  upon 
the  skin  produces  a  well-known  reactive  hyperemia,  though  the 
technic  of  its  application  demands  that  the  area  to  be  treated 
should  be  made  as  exsanguine  as  possible  by  pressure  in  order 
to  permit  the  passage  of  ultraviolet  rays  to  the  skin.  With 
this  end  in  view  an  attendant  is  required  to  press  firmly  upon 
the  patch  of  skin  subjected  to  the  ray  a  cell  of  quartz  crys- 
tal through  which  water  continuously  flows  and  which  is  held 
in  position  during  the  entire  seance." 

INCANDESCENT    LIGHT 

Numerous  therapeutic  incandescent  lamps  have  been  placed 
on  the  market,  a  number  of  which  have  been  made  the  subjects 
of  extravagant  claims  with  reference  to  the  cure  of  all  manner 
of  diseases,  including  cancer.     These  lamps  range  from  fifty 

1  Finsen,  Niels  E. — *  *  The  Treatment  of  Lupus  Vulgaris  by  Concentrated 
Chemical  Eays":       .         .     1897.     Appendix  to  "Phototherapy, "  1901. 

See  also :  ' '  Modd.  om  de  hidtil  opnaaede  Resultatear  af  Behandlingen  af 
Hudepitheliomer  med.  konc.  Lys, ' '  Dermat.  Selslcabs  Forhandh,  1899-1900. 

-  Peterson,  O.  V. — ' '  Progress  of  Phototherapy  by  Finsen  'a  Method, ' ' 
Vrach,  St.  Petersburg,  1901,  XXII,  1369. 

3  Burgsdorf ,  V. — ' '  Curative  and  Noxious  Powers  of  Light, ' '  Kazan  Med, 
Jour.,  1902,  Vol.  II,  517-528. 

4  Hyde,  James  Nevins. — ' '  On  the  Influence  of  Light  in  the  Production 
of  Cancer  of  the  Skin,"  Am.  Jour,  of  Med.  Sciences,  January,  1906,  p.  1. 


PHYSIOTHERAPY  291 

to  seven  hundred  candle  power,  and  have  diverse  reflectors  and 
other  appurtenances  for  the  supposed  augmentation  of  thera- 
peutic value.  The  Leucodescent  Lamp  has  been  employed  for 
this  purpose,  as  have  doubtless  other  incandescent  lamps;  but 
I  have  been  unable  to  find  a  reliable  record  of  the  use  of  any 
form  of  incandescent  lamp  in  the  treatment  of  any  form  of 
cancer.  It  may  be  said,  however,  that  no  conclusive  trial  seems 
to  have  been  made  of  any  of  them.  It  may  not  be  denied, 
therefore,  that  they  might  prove  useful  as  adjuvant  measures 
for  the  relief  of  pain  and  other  symptoms  of  advanced  and 
irremovable  cancer,  and  for  the  clearing  up  of  discharges  and 
cachexia. 

FLUORESCENT    STIMULATION 

Von  Tappeiner  and  Jesionek,^  Tousey,^  and  others,  have 
experimented  with  fluorescent  substances  in  the  treatment  of 
malignant  diseases. 

Von  Tappeiner  and  Jesionek  treated  three  cases  of  cutaneous 
cancer  by  painting  the  lesions,  at  frequent  intervals,  with  a 
five  per  cent,  aqueous  solution  of  eosin,  immediately  thereupon 
exposing  the  part  to  the  rays  of  the  sun  or  to  the  light  of  an 
electric  lamp.  In  each  case  (cancer  of  the  face)  the  ulcerated 
surfaces  became  covered  with  good  granulations,  the  lesions 
"evoluting  toward  a  cure."  Quinin,  esculin,  and  fluorescin 
have  also  been  used  in  connection  with  X-rays  and  radium. 
Quinin,  in  five-grain  doses,  and  esculin,  in  one-grain  doses,  in 
dilute  solutions,  have  been  administered  internally,  a  few  hours 
before  treatment  with  X-rays  or  radium. 

Tousey's  experiments' led  him  to  conclude  ^  that  the  various 
fluorescent  media  which  have  been  given  internally  in  conjunc- 
tion with  the  application  of  X-rays  have  no  beneficial  result 
due  to  the  luminosity  excited. 

X-RAYS 

It  is  claimed  *  that  the  X-rays,  discovered  by  Rontgen,^  in 

1  Von  Tappeiner  and  Jesionek. — ' '  Therapeutische  Versuche  mit  fluorea- 
zierenden  Stoffen,"  Miinch.  med.  Woch.,  Nov.  24,  1903,  p.  2042;  abstr.  in 
Semaine  med.,  1903,  p.  422;  and  in  Revue  International  d'Electrotherapie, 
January,  1904,  No.  13,  p.  212. 

2  Tousey,  Sinclair. — ' '  Medical  Electricity  and  Kontgen  Eays, ' '  1910. 

3  Op.  cit. 

4  Johnson  and  Merrill. — '  *  The  X-rays  in  the  Treatment  of  Carcinoma, ' ' 
Phila.  Med.  Jour.,  1900,  Vol.  6,  p.  1089. 

5  Eontgen  was  studying  the  properties  of  the  cathode  rays  in  a  par- 
tially exhausted  tube — Crookes  tube.  Crystals  of  barium  platinocyanide 
in  the  vicinity  of  the  tube  became  fluorescent,  and,  upon  investigation 
Eontgen  found  that  the  luminosity  was  due  to  an  undiscovered  ray,  which 
he  named  the  X-ray. 


292  THE   CANCER    PROBLEM 

1895,  were  first  employed  in  tlie  treatment  of  malignant  dis- 
eases. The  history  of  the  therapeutic  nse  of  the  rays  has  since 
verified  the  prophecy  made  by  Adams  in  1792,  quoted  at  the 
beginning-  of  this  section. 

Extravagant  claims  have  been  made  concerning  the  curative 
property  of  this  agent,  and  it  will  doubtless  continue  to  have 
its  adherents  until  we  gain  more  definite  knowledge  concern- 
ing the  action  of  the  rays  and  the  nature  of  cancer. 

The  causal  relation  of  X-rays  to  cancer  has  been  made  the 
subject  of  considerable  experimental  work.  In  1907  Porter 
and  White  ^  collected  from  the  literature  ten  undoubted  cases 
of  skin  cancer  produced  by  the  action  of  the  rays,  adding  one 
case  from  personal  experience.  Since  that  time  the  list  has 
been  considerably  lengthened,  many  investigators  having  fallen 
victims  to  malignant  disease,  presumably  in  consequence  of  the 
action  of  the  rays  upon  the  skin. 

Rowntree,^  accepting  the  well-established  fact  that  prolonged 
exposures  to  X-rays  have  resulted  in  the  production  of  a  new 
growth,  which  seemed  identical,  by  microscopic  examination, 
with  squamous-celled  carcinoma,  proceeded  to  study  the  patho- 
logical changes  set  up.  His  studies  consisted  of  the  examination 
of  specimens  of  five  cases  of  carcinoma  arising  in  X-ray  work- 
ers, in  investigations  carried  out  on  patients  in  cancer  wards  of 
the  Middlesex  Hospital,  and  in  experiments  with  rats. 

Microscopic  study  of  the  specimens  upon  which  his  report 
was  founded  left  no  difficulty  in  accepting  them  as  examples 
of  typical  squamous-celled  carcinoma. 

The  rats  upon  which  experiments  were  conducted  were 
placed  in  small  lead  cages  which  completely  protected  their 
bodies,  while  allowing  their  tails  to  project  from  a  small  hole. 
Exposure  to  the  direct  action  of  the  X-rays  involved  only  the 
dorsal  surface  of  the  tail.  When  thus  exposed  for  a  long  time, 
marked  dermatitis  followed,  the  entire  circumference  of  the 
tail  being  affected  at  the  tip  where  movement  in  all  directions 
was  possible.  Nearer  the  base,  where  only  the  dorsal  surface 
was  exposed,  the  changes  were  confined  to  this  surface  and 
were  well  defined.  The  ventral  surface  in  the  locality  was 
normal.  The  diseased  surface  showed  disappearance  of  the 
surface  epithelium,  the  hair  bulbs,  and  the  sebaceous  glands, 
and  the  formation  of  granulation  tissue.  The  intermediate 
zones  showed  thickening,   with  slight  irregularity  of  surface 

1  Porter  and  White. — ' '  Multiple  Carcinomata  Following  Chronic  X-ray 
Dermatitis,"  Annals  of  Surgery,  1907,  Vol.  46,  p.  649. 

2  Rowntree,  Cecil  W. — ' '  Contribution  to  the  Study  of  X-ray  Carcinoma 
and  the  Conditions  Which  Precede  Its  Onset, ' '  Archives  of  Middlesex  Hos- 
pital,  1908,  Vol.  XIII,  p.   182,  and  Vol.  XV,  1909,  p.   192. 


PHYSIOTHERAPY  293 

epithelium  and  hypertrophy  of  the  hair  follicles.  After  expo- 
sure sufficient  to  produce  severe  dermatitis,  the  bones  showed 
a  considerable  degree  of  alteration,  giving  a  much  lighter 
shadow  on  the  skiagraphic  plate  than  the  normal  bone. 

From  his  experiments  Rowntree  concluded  as  follows : 

^'1.  That  the  application  of  X-rays  to  healthy  tissue  in 
moderate  doses — what  may  be  regarded  as  a  moderate  dose 
probably  varying  considerably  with  the  idiosyncrasy  of  the  in- 
dividual— results  in  stimulation  of  normal  physiologic  proc- 
esses, i.  e.,  the  growth  of  epithelial  and  other  cell  elements, 
hairs,  etc. 

"2.  That  a  single  large  dose  may  result  in  an  acute  change 
somewhat  resembling  an  ordinary  burn  or  other  form  of  de- 
structive dermatitis. 

"3.  Administration  of  doses  for  a  long  period  ultimately 
results  in  complete  atrophy  of  the  epithelial  elements  and  de- 
generative changes  in  the  connective  tissues. 

"4.  That  the  conditions  contained  in  1  and  3  ultimately 
result  in  a  state  which  disposes  to  the  occurrence  of  carcinoma. 
Whether  the  formation  of  epithelial  new  growths  is  simply  due 
to  the  chronic  irritation  abundantly  present  in  these  cases,  or 
whether  the  X-rays  by  their  action  exert  some  special  influence, 
it  is  at  present  impossible  to  say." 

Clunet,^  on  the  other  hand,  conducted  experiments  which 
led  to  more  positive  results.  He  produced  a  destructive  ulcera- 
tive radiodermatitis  in  white  rats.  As  soon  as  this  ulceration 
was  ready  to  heal,  radiation  was  again  applied.  At  the  end  of 
five  months,  after  several  spontaneous  tendencies  to  heal,  which 
were  at  once  interrupted  by  a  new  exposure,  the  X-ray  ulcers 
had  become  sufficiently  established  to  show  no  tendency  toward 
repair  during  nine  months,  although  no  longer  exposed  to  the 
rays.  One  of  the  four  rats  treated  in  this  manner  developed, 
nine  months  after  the  last  exposure,  a  tumor  upon  the  X-ray 
ulceration.  This  tumor  recurred  after  operative  removal,  and 
six  weeks  later  caused  the  death  of  the  animal.  Histological 
examination  showed  this  tumor  to  consist  entirely  of  connective 
tissue  elements  of  very  unequal  size  and  variable  morphology, 
representing  an  unusual  type  of  sarcoma.  This  was  the  first 
instance  of  the  experimental  production  of  cancer  by  X-rays. 

1  Clunet,  J. — '  *  Tumeur  developpee  sur  une  radiodermite  experimentale, ' ' 
Eecherehes  Experimentales  sur  les  Tumeurs  Malignes,  Paris,  1910,  Chap. 
X,  p.  297. 

See  also:  Marie,  Clunet,  and  Eaulot-Lapointe. — "Contribution  a  1 'etude 
du  developpement  des  tumeurs  malignes  sur  les  uleeres  de  Eoentgen, ' '  Bull, 
de  r Association  frangaise  pour  V etude  du  cancer,  1910,  No.  3,  p.  404. 


294  THE   CANCER    PROBLEM 

Marie,  Chmet,  and  Raulot-Lapointe  ^  reported  further  ex- 
perimentation, resulting  in  the  production  of  malignant  tumors 
following  X-ray  dermatitis  in  two  white  rats.  In  the  first  case 
the  tumor  could  not  be  grafted  on  other  animals,  whereas  the 
second,  which  developed  under  identical  conditions,  could  be 
transmitted  through  other  animals. 

It  has  not  been  determined  exactly  how  X-rays  affect  cancer 
cells,  whether  by  a  direct  action  or  by  an  electrolytic  process. 

Schmidt  -  conducted  a  series  of  experiments  with  plants  in 
order  to  determine  the  action  of  X-rays.  He  soaked  a  number 
of  beans  in  water  for  six  hours,  treated  different  beans  with 
different  doses  of  X-rays,  then  planted  them.  The  beans  which 
were  given  large  doses  were  more  or  less  completely  inhibited 
in  growth,  whereas  those  wdiich  received  small  doses  were  so 
stimulated  that,  compared  with  the  untreated  beans  and  those 
receiving  large  doses,  the  plants  were  larger  and  more  vigor- 
ous, the  flowers  were  larger,  and  the  production  of  beans  bet- 
ter. These  findings  led  him  to  believe  that  animal  cells  might 
respond  in  like  manner  to  varying  degrees  of  the  rays.  He 
experimented  upon  a  sluggish  ulcer  on  the  arm,  which  verified 
the  findings  in  the  case  of  the  beans.  This  led  naturally  to 
three  conclusions : 

1.  That,  in  treating  indolent  ulcers  and  other  conditions  in 
which  healing  and  cell  proliferation  are  sought,  very  small 
doses  of  the  X-ray  should  be  given. 

2.  In  malignant  growths,  when  the  destruction  of  tissue  is 
the  purpose,  large  doses  should  be  administered. 

3.  That  small  doses,  in  the  case  of  malignant  growths,  may 
stimulate  cell  proliferation  and  thereupon  lead  to  renewed 
activity. 

If  Schmidt's  experiments  are  to  be  accepted  as  leading  to 
correct  conclusions,  it  is  easily  to  be  seen  that  the  X-ray,  unless 
used  in  sufficient  dosage,  is  not  only  an  agent  of  little  value  in 
the  treatment  of  malignant  disease,  but  that  it  is,  or  may  be, 
fraught  with  distinct  harm,  even  to  the  production  of  malig- 
nant neoplasms. 

Coolidge  ^  has  described  a  new  X-ray  tube  which  marks  an 
advance  in  X-ray  science.  The  tube  is  so  constructed  that  the 
penetration  and  intensity  of  the  ray  are  under  the  complete 

1  Marie,  Clunet,  and  Eaulot-Lapointe. — ' '  Nouveau  cas  de  tumeur  malice 
provoquee  par  une  radiodermite  experimentale  chez  le  rat  blanc, ' '  Bull,  de 
r Assoc,  frangaise  four  V etude  du  cancer,  1912,  No.  6,  p.  125. 

2  Schmidt,  H.  E. — ' '  Experimentelle  Untersuchen  iiber  die  wirkung^ 
kleinerer  und  grosserer  Eontgenstrahlen-mengen  auf  pinge  Zellen, "  Berl. 
Min.   Woch.,   1910,  Vol.  XLVII,  p.  972. 

3  Coolidge,  W.  D. — Physical  Revieiv  of  the  American  Physical  Society, 
December,  1913. 


PHYSIOTHERAPY  295 

control  of  the  operator  at  all  times.  A  very  high  degree  of 
penetration  can  be  obtained — of  the  greatest  advantage  in  the 
treatment  of  deep-seated  cancer.  The  time  of  application  is 
materially  decreased.  This  tube  is  still  on  trial.  It  may  be 
that  the  extremely  hard  rays  produced  by  it  may  act  similarly 
to  the  gamma  rays  of  radium. 

Kassabian,^  who  fell  a  victim  to  X-ray  cancer,  gave  a  digest, 
in  1910,  of  the  work  of  others  in  the  use  of  X-rays  in  the 
treatment  of  epithelioma,  carcinoma,  and  sarcoma.  He  found 
a  great  diversity  of  opinion. 

In  the  treatment  of  epithelioma,  he  said :  "Some  prefer  the 
soft  and  others  the  hard  tube.  Views  also  vary  as  to  the  dura- 
tion of  the  seances  and  their  frequency.  It  is  asserted  by  some 
that  a  slight  dermatitis  is  always  to  be  aimed  at,  in  order  to 
obtain  the  proper  action.  The  great  variety  of  the  cases  en- 
countered will  allow  no  special  technic ;  the  peculiarities  of  the 
epitheliomas  themselves  will  frequently  dictate  the  method  to 
be  pursued." 

Reports  of  X-ray  therapeutists,  according  to  Kassabian,  are 
widely  divergent  as  to  the  value  of  X-rays  in  the  treatment  of 
cancer.  He  expressed  the  opinion  that  this  is  largely  due  to 
the  use  of  inefficient  apparatus  and  to  errors  in  diagnosis,  be- 
nign growths  being  mistaken  for  malignant  ones.  He  empha- 
sized, in  this  connection,  the  importance  of  examining  micro- 
scopically, before,  during,  and  after  irradiation,  sections  or 
scrapings  of  the  growth. 

"Probably  we  err  too  much,"  he  said,  "on  the  side  of  safety ; 
apparently  the  seances  are  too  brief,  we  too  often  fearing  the 
production  of  a  severe  type  of  dermatitis."  He  advised  and 
always  used,  short,  and  frequently  repeated,  exposures. 

MacKee  ^  favors  single  massive  doses  of  X-ray  in  the  treat- 
ment of  epithelioma,  and  claims  that  the  repeated  small  doses 
may  result  in  the  production  of  a  resistance  to  the  beneficial 
action  of  the  rays. 

Coley  ^  reported  sixty-eight  cases  of  sarcoma  treated  by 
X-rays,  in  six  of  which  there  was  complete  disappearance  of 
the  disease.  In  each  of  these  cases,  however,  there  was  recur- 
rence within  a  few  months. 

Bythell  and  Barclay"*  state  that  "sarcomata  respond  more 
readily  to  X-ray  treatment  than  either  carcinomata  or  epithe- 

1  Kassabian,  Mihran  Krikor. — ' '  Eontgen  Eays  and  Electrotherapeutics, 
With  Chapters  on  Radium  and  Phototherapy,"  1910. 

2  MacKee,  George  M. — ' '  Epithelioma  Treated  with  the  Massive-Dose 
Method,"  Jour,  of  Cutaneous  Diseases,  1913,  Vol.  31,  p.  411. 

3  Coley,  W.  B.— ' '  Later  Results  of  the  X-ray  Treatment  of  Sarcoma, ' ' 
Archives  of  Physiol.   Therapy,  1906,  Vol.  Ill,  p.   161. 

4  Bythell   and   Barclay,   "X-ray   Diagnosis   and   Treatment,"    1912. 


296  THE   CANCER   PROBLEM 

liomata,  but  metastatic  deposits  make  their  appearance  at  a 
very  earlv  stage  in  the  malignant  types."  "In  our  own  prac- 
tice," they  report,  "we  have  had  three  cases  that  have  been  ap- 
parently cured — one  in  a  case  affecting  the  palate,  and  two 
cases  of  abdominal  sarcoma  in  children." 

Schultz  ^  says :  "There  is  hardly  any  object  in  treating 
large  sarcomata,  and  especially  so  if  they  reach  to  the  perios- 
teum or  if  they  start  from  the  bones.  On  the  other  hand, 
smaller  nodules,  up  to  the  size  of  a  nut,  whether  they  are  intra- 
or  subcutaneous,  are  often  favorably  influenced,  likewise  also 
primary  or  metastatic  sarcomatous  lymphatic  glands  provided 
they  do  not  exceed  the  size  of  a  hen's  egg." 

Jones  "  considers  that,  while  there  is  a  quantity  of  evidence 
to  support  the  contention  that  X-rays  act  beneficially  in  malig- 
nant disease,  "the  amount  of  evidence  to  show  that  cures  have 
resulted  is  lamentably  meager,  and  we  cannot  yet  suggest  any 
explanation  why  an  agent  which  very  commonly  gives  relief 
to  some  of  the  symptoms  produced  by  malignant  growth  should 
fail  to  give  the  complete  relief  which  is  really  required,  and 
we  are  almost  forced  to  believe  that  it  must  be  from  some  in- 
herent defect  of  the  method  of  a  fundamental  kind." 

In  the  Purvis  lecture,  on  The  Treatment  of  Inoperable  Can- 
cer, given  before  the  West  Kent  Medico-chirurgical  Society  on 
December  6,  1912,  Sir  Alfred  Pearce  Gould, ^  has  this  to  say 
of  the  X-ray :  "By  the  use  of  X-rays  in  cancer  of  the  breast  I 
have  seen  foul  ulcers  cleaned,  and  some  ulcers  healed  up  en- 
tirely; I  have  repeatedly  seen  small  secondary  nodules  in  the 
skin  and  fascia  disappear ;  I  have  had  several  cases  when  larger 
and  deeper  secondary  growths,  involving  muscle,  ribs,  rib-car- 
tilages, or  sternum,  have  disappeared,  and  in  other  cases  such 
growths  have  remained  stationary  and  quiescent  for  such  long 
periods  that  I  could  only  think  the  radiations  had  had  at  least 
an  inliibitory  influence  upon  the  growth.  But  in  view  of  the 
extreme  and  remarkable  natural  variations  that  occur  in  cases 
of  cancer,  apart  altogether  from  treatment,  I  desire  to  speak 
with  great  reserve  upon  this  point." 

Eontgen  rays  have  been  employed  in  conjunction  with  other 
agents  (see  Fluorescent  Stimulation,  page  291),  and  other 
methods  (see  Thermo-radiotherapy,  page  317),  in  the  treatment 
of  cancer. 

1  Schultz,  F. — ' '  The  X-ray  Treatment  of  Skin  Diseases. ' '  Trans,  by 
James  Burnet,   New  York,   1910. 

2  Jones,  Henry  Lewis. — ' '  Medical  Electricity, ' '  London,  1906,  5th  ed., 
p.  373. 

3  Pearce  Gould,  Sir  Alfred. — Archives  of  the  Roentgen  Bay,  March,  1913, 
Vol.  17,  p.  399. 


PHYSIOTHERAPY  297 

RADIO-ACTIVITY 
RADIUM 

Sir  Malcolm  Morris,  in  the  preface  to  the  English  edition  of 
Wickham's  book  ^  (the  first  treatise  on  radium,  therapy),  ex- 
pressed an  opinion  parallel  with  that  voiced  by  Adams  in  1792  : 
"The  medical  profession  is  as  eager  as  were  the  Athenians  of 
old  to  hear  of  any  new  thing;  and  it  is  somewhat  prone  to 
welcome  a  therapeutic  novelty  with  excessive  enthusiasm,  and, 
when  the  inevitable  reaction  occurs,  to  dismiss  it  with  perhaps 
undeserved  depreciation." 

"To  this  general  rule  of  the  formation  of  medical  opinion," 
he  continues,  "radium  has  been  no  exception.  On  the  strength 
of  some  exaggerated  statements  it  has  been  hailed  as  the  long- 
expected  cure  for  cancer ;  and  the  notion  of  radio-activity  has 
inflamed  some  minds  to  a  degree  far  beyond  anything  for  which 
the  facts  so  far  ascertained  afford  justification.  It  is  scarcely 
too  much  to  say  that,  but  for  the  judicial  temper  brought  by 
Dr.  Wickham  to  the  study  of  the  problem,  radium,  whatever 
potency  of  healing  it  holds  in  itself,  would  have  been  relegated, 
as  other  remedies  have  been,  to  the  limbo  of  charlatanism." 

The  words  of  Morris  are  particularly  pertinent  just  now,  in 
view  of  the  recent  widespread  interest  in  radium  in  the  United 
States.  So  much  has  been  said  concerning  the  matter,  in  both 
the  medical  and  the  lay  press,  that  it  needs  no  elaboration  here. 

After  the  discovery  of  the  X-ray,  in  1895,  Becquerel,  acting 
upon  a  suggestion  of  Poincare,  demonstrated  the  presence  of 
penetrative  rays  in  salts  of  uranium.  Mme.  Curie  carried  on 
the  experiments,  and  in  1898-1900  isolated  two  radio-active  ele- 
ments from  pitchblende  (oxid  of  uranium),  which  she  named 
polonium  and  radium. 

Kadium  emits  three  kinds  of  invisible  rays — alpha,  beta, 
and  gamma,  and  a  radio-active  gas  called  the  emanation,  which 
again  splits  up  into  other  products.  Radium  A,  Radium  B,  etc. 

The  alpha  rays  are  easily  absorbed,  even  by  a  sheet  of  wri- 
ting paper.  The  beta  rays  are  of  different  penetrative  qual- 
ities, but  the  most  penetrative  are  absorbed  by  about  2  mm.  of 
lead.  The  gamma  rays  readily  penetrate  several  inches  of 
lead.  The  emanation  possesses  the  activity  of  the  radium  itself, 
but  has  the  disadvantage  of  losing  its  properties  in  a  month. 

The  apparatus  employed  in  treatment  consists  of :     ( 1 )  Flat 

1  Wickham  and  Degrais,  "Eadium  Therapy."  Trans,  by  S.  E.  Dore, 
1910.  See  also:  "Radium  and  Cancer, "  London,  1913.  Trans,  by  A.  and 
A.  G.  Bateman. 


298  THE   CANCER    PROBLEM 

varnish  applicators  for  use  in  treating  superficial  lesions;  (2) 
capillary  glass  tubes  containing  a  radium  salt  and  enclosed  in 
a  silver  tube.  These  are  mainly  used  in  cavities  or  buried  in 
malignant  growths.  (3)  The  emanation,  collected  in  glass  or 
silver  containers.  It  may  be  dissolved  in  saline  solution  or 
distilled  water  and  injected  into  the  tumor.  In  any  case  suit- 
able screens  of  aluminum,  silver,  or  lead  must  be  employed  to 
filter  out  the  irritant  rays,  viz.,  the  alpha  and  soft  beta  rays. 

Shortly  after  the  discovery  of  radium,  Danlos  ^  made  the 
first  therapeutic  researches  with  the  substance.  After  a  series 
of  experiments,  extending  over  three  years,  Danlos  concluded 
that  radium,  employed  wet  or  dry,  exerted  a  curative  action 
upon  the  majority  of  benign  epitheliomata. 

The  pioneers  in  the  therapeutic  use  of  radium  (Exner,  Rol- 
lins, Beclere,  Darier,  Sichel,  Williams,  Krylov,  Lassar,  Fol- 
lard,  Repmann,  Matzenstaum,  Branstein,  Mackenzie  Davidson, 
Abbe,  and  many  others)  reported  very  few  successes  in  the 
treatment  of  maligiiant  neoplasms.  Their  many  successes  in 
the  treatment  of  benign  neoplasms  did  not  counterbalance  their 
failures  with  malignant  growths,  and  so,  despite  some  extrava- 
gant claims  of  cures,  radium-therapy  made  little  real  progress 
until  Wickham  began  his  extensive  investigations  in  1905. 

Wickham  and  DegTais,"  in  1910,  reported  various  degrees  of 
improvement  in  the  treatment  of  grave  malignant  neoplasms 
(1)  in  the  skin  and  subcutaneous  tissue;  (2)  in  lymphatic 
glands;  (3)  in  the  breast;  (4)  in  the  buccal  mucous  mem- 
brane ;  (  5  )  in  the  uterus. 

In  discussing  the  treatment  of  cancers  in  general  by  radium- 
therapy,  these  authors  (p.  157)  warned  against  conclusions 
based  on  cases  which  are  few  in  number  and  which  have  been 
recently  treated. 

The  most  striking  point  in  the  investigations  of  Wickham 
and  Degrais  was  that  the  results  obtained  were  not  confined  to 
small  epitheliomata,  and  were  far  better  than  those  obtained 
by  the  first  observers.  "In  lesions  for  which  there  is  no  hope 
of  cure,"  they  report,  "it  is  sometimes  possible  to  prolong  the 
lives  of  patients,  and  to  relieve  their  sufferings,  even  in  cases 
where  surgical,  electrical,  or  X-ray  treatment  can  no  longer  be 
employed  with  advantage.  In  ulcerating  neoplasms  one  usually 
observes,  in  the  first  place,  arrest  of  pain,  hemorrhage,  and  dis- 
charge, and  the  disappearance  of  offensive  odor;  analgesia  and 
diminution  of  congestion  afford  great  relief  in  subcutaneous 

1  Danlos,  H. — "Sur  Taction  physiologique  et  therapeutique  du  radium," 
Bull.   d.   Sc.   Pharmacol.,   Paris,    1904,    IX,   65-74. 

2  Op.  cit. 


PHYSIOTHERAPY  299 

neoplasms."  "In  growths  of  less  serious  character,"  they  con- 
tinue, "the  improvement  does  not  stop  here,  but  is  accompanied 
bj  other  symptoms  of  resolution.  Tissues  are  modified ;  the 
tumors  become  detached  from  their  adherent  bases,  and  dimin- 
ish in  size ;  vegetations  subside  and  disappear ;  ulcers  become 
cicatrised  and  gradually  replaced  by  new  tissues  of  excellent 
appearance.  Subcutaneous  neoplasms,  in  consequence  of  their 
fibrous  transformation,  frequently  leave  hard,  indolent,  and 
movable  foci  after  treatment." 

Successful  results  are  reported  by  Wickham  and  Degrais  in 
the  treatment  of  tumors  of  various  kinds — lymphadenoma,  sar- 
coma, lymphosarcoma,  and  mycosis  fungoides.  Their  efforts 
v^ere  not  confined  to  malignant  neoplasms  which  are  easily 
accessible.  Those  which  are  accessible  only  with  difficulty  are 
not  especially  mentioned,  examples  thereof  being  recent,  and 
their  study  still  proceeding,  yet  some  of  the  results  obtained, 
they  claim,  are  sufficiently  clear  and  precise  to  permit  them  to 
assert  the  value  of  radium  in  a  larger  field  than  had  hitherto 
been  thought  possible. 

Dominici  ^  suggested  the  idea  of  removing  the  injurious  ele- 
ments from  the  radium  rays,  meaning  the  easily  absorbed  alpha 
and  beta  rays.  Although  90  per  cent,  of  the  total  radiation  is 
lost  by  this  removal,  the  remainder  is  still  strong  enough  for 
the  accomplishment  of  various  therapeutic  effects.  The  tech- 
nic  is  very  simple:  The  source  of  the  rays  is  surrounded  by 
thin  leaden  plates  (which  exclude  the  harmful  rays),  which 
are  encased  in  paper,  to  prevent  secondary  rays;  the  entire 
piece,  which  may  be  of  any  desired  size,  is  then  wrapped  in  a 
rubber  sheet.  This  contrivance  is  either  fixed  on  the  outside, 
on  the  affected  spot,  or  it  may  be  introduced  through  a  small 
incision  into  the  interior  of  a  tumor,  where  it  may  be  left  with- 
out interruption,  up  to  120  hours,  or  it  may  be  removed  and 
replaced  at  arbitrary  intervals. 

A  series  of  cured  cases  were  those  of  cancroids  of  the  face,  the 
nose,  or  the  penis;  carcinomata  of  the  superior  maxilla,  the 
uterus,  and  the  breast.  Sarcomata,  lymph  sarcomata,  and 
adenomata  were  also  completely  removed  in  this  manner. 

Dominici  and  Martel^  endeavored  to  destroy  carcinomata  of 
the  tongue  by  the  introduction  of  small  tubes  containing  radium, 
permitting  only  the  passage  of  the  ultra-penetrating  rays  into 
the  core  of  the  tumor.     The  technic  is  original  and  consists  in 

1  Dominici,  M.  H. — ' '  Du  traitement  des  tumeurs  malignes  par  le  rajon- 
ment  ultra-penetrant  du  Eadium, "  Bull,  de  I' Assoc.  Frangaise  pour  l^ etude 
du  cancer,  Tome  I,  1908,  in  Bevue  de  Medecine,  1909,  p.  124. 

2  Dominici  and  de  Martel. — ' '  Radiumth^rapie  du  cancer  de  la  langue, ' ' 
La  Presse  medicale,  No.  18,  1910,  p.  155. 


300  THE   CANCER    PROBLEM 

transfixing  the  tumor  and  the  tongue  with  a  thick  needle,  which 
draws  after  it  and  phices  in  position  the  radium-containing  tuhe. 
Sometimes  the  radium-tube  is  inserted  into  a  screw,  which  was 
especially  constructed  for  this  purpose,  and  the  whole  mass  is 
slowly  driven  into  the  tumor. 

This  method  of  introducing  the  source  of  the  radium  rays 
into  the  center  of  the  tumor  had  already  been  used  by  other 
investigators  for  various  visceral  tumors,  but  with  rather  im- 
perfect and  inappropriate  instruments.  The  results  obtained 
by  these  authors,  however,  were  satisfactory,  and  consisted  in 
softening  of  the  tumor  mass,  cessation  of  the  hemorrhage,  and 
relief  of  pain,  as  well  as  a  retrogression  of  the  tumor. 

Exner  ^  reported  four  cases  of  cancer  of  the  cheek  and  lips, 
not  well  adapted  to  operative  removal,  in  which,  by  means  of 
radium  radiation,  a  cure  was  effected.  That  is  to  say,  there 
was  no  recurrence  for  from  two  to  seven  years,  up  to  the  time 
of  death  from  another  cause,  or  until  the  time  of  the  report. 
Exner  especially  emphasized  the  efficiency  of  radium  treatment 
in  certain  cases  with  unfavorable  prognoses. 

In  inoperable  cases  radium  seems  to  have  a  distinct  place  of 
usefulness.  Warden,^  of  Paris,  reports  cases  which,  in  his 
estimation,  warrant  this  conclusion. 

Finzi  ^  reported  117  inoperable  carcinomata,  not  including 
cases  of  rodent  ulcer,  which  were  subjected  to  radium  treat- 
ment, with  the  result  that  a  complete  local  retrogression  was 
obtained  in  12  per  cent,  and  relief  of  pain  in  62  per  cent. 
Radium  should  be  employed,  in  his  opinion,  in  all  incurable 
cancers,  also  as  a  prophylactic  measure  after  every  cancer 
operation.  Especially  favorable  effects  are  to  be  anticipated 
from  large  amounts  of  radium. 

Finzi  emphasizes  the  fact  that  the  effect  of  radium  is  not 
confined  to  superficial  growths,  but  may  be  obtained  in  deep 
growths,  if  care  is  taken  to  filter  the  rays  in  order  to  get  the 
selective  action. 

1  Exner. — ' '  Ueber  Dauerheilungen  von  Karzinom  nach  Eadiumbestrah- 
Inng,"  Munch,   med.  WocJi.,  1910,  No.  57,  p.  2472. 

See  also:  Sitzungsher.  d.  E.  K.  Akad.  Wissensch.,  Wien,  1903,  Vol. 
CXII,    Abt.   Ill,   p.    285. 

Exner  and  Holzknecht. — ' '  Die  Pathologic  der  Kadiumdermatitis, ' '  ibid., 
p.  155. 

Exner. — Wien.  Jclin.  Woch.,  1904,  p.  96;  ibid.,  p.  181.  Deut.  Zeitschr.  f. 
Chir.,  Vol.  75,  1905,  p.  379. 

2  Warden,  A.  A. — * '  Radium  and  Inoperable  Cancer, ' '  Brit.  Med.  Jour., 
1913,  Vol.  2,  p.  1067. 

Also:  Dominici  and  Warden. — "The  Technique  and  Results  of  Radium- 
therapy  in  Malignant  Disease,"  Brit.  Med.  Jour.,  1910,  Vol.  2,  p.  516. 

3  Finzi,  N.  S. — "The  Radium  Treatment  of  Cancer,"  TJie  Lancet,  May 
20,  1911. 

See  also:     Finzi,  "Radium  Therapeutics,"  London,   1913. 


PHYSIOTHERAPY  301 

How  this  selection  is  brought  about  is  not  known.  Accord- 
ing to  Finzi  it  is  not  due  to  anything  actually  introduced  from 
the  radium,  the  gamma  rays  being  held  to  be  "merely  ether 
pulses  and  not  material  particles."  "It  has  been  suggested," 
he  continues,  "that  the  cells  of  a  cancer  are  more  easily  dam- 
aged than  the  healthy  cells  surrounding  them,  and  that  any 
agent  which  injures  the  tissues  will  attack  them  first."  He 
does  not  accept  this  view,  calling  attention  to  the  fact  that  the 
gamma  rays  are  much  more  powerful  than  X-rays  in  picking 
out  the  cells  of  the  neoplasms,  and  infinitely  more  powerful 
than  a  simple  irritant.  Treated  with  radium  (filtered  rays),  a 
growth  can  be  made  to  disappear  with  no  evidence  of  any  in- 
flammation. 

When  a  full  dose  of  radium  rays,  filtered  through  1-1.2  mm. 
of  lead  or  platinum,  is  used  on  the  skin  a  double  reaction  is 
frequently  noted;  (1)  an  erythema,  beginning  about  a  fort- 
night after  the  treatment,  and  gradually  fading  away;  (2)  a 
pigmentation  appearing  about  five  weeks  after  treatment.  The 
first  is  probably  due  to  the  beta  rays  which  have  escaped 
through  the  filter,  and  the  second  to  the  gamma  rays. 

Answering  the  question,  "Does  the  absorption  of  a  tumor 
have  any  efi^ect  on  metastasis  ?"  Finzi  claims  to  have  evidence 
that,  in  some  cases,  a  metastasis  may  retrogress  on  the  treat- 
ment of  the  primary  growth  or  another  metastasis.  He  is  of 
the  opinion  that  the  destruction  and  absorption  of  the  cancer 
cells  should  cause  the  formation  of  antibodies,  and  that  these, 
in  their  turn,  should  lead  to  the  destruction  and  absorption  of 
other  cancer  cells. 

With  reference  to  the  possible  acceleration  of  growth  of  can- 
cer cells  under  the  selective  action  of  radium,  Finzi  holds  an 
afiirmative  opinion.  In  this  connection  he  advocates  the  treat- 
ment of  the  whole  growth  thoroughly,  as  well  as  all  outlying 
deposits  of  cancer. 

The  action  of  radium  rays  upon  a  malignant  growth  does 
not  become  apparent  at  once.  The  earliest  changes  noted  by 
Finzi  have  been,  a  marked  diminution  of  pain  in  one  case,  of 
swelling  in  another,  and  of  fetor  and  discharge  in  others,  occur- 
ring about  one  and  a  half  days  after  the  commencement  of  the 
application.  These  changes,  together  with  the  shrinkage  of 
the  growth,  reach  a  maximum  in  four  or  five  weeks.  Toxemia, 
which  occurs  in  many  readily  absorbed  tumors,  may  be  noted 
from  the  third  day,  generally  lasting  about  two  weeks. 

The  nature  of  the  malignant  growth,  the  position  and  size  of 
the  deposits,  and  the  general  condition  of  the  patient,  are  all 
conceded  to  affect  the  successful  use  of  radium.     Some  tumors, 


302  THE   CANCER   PROBLEM 

however  small,  fail  to  respond  to  radium  treatment.  This  is 
particularly  applicable  to  epitheliomata  of  the  tongue  and 
vulva. 

The  general  rules  laid  down  by  Finzi  for  the  application  of 
radium  radiations  are:  (1)  treat  thoroughly  the  whole  tumor 
and  the  site  of  any  possible  metastases;  (2)  adequately  filter 
the  rays;  (3)  use  as  large  an  amount  of  radium  as  possible; 
(4)  give  maximum  exposures. 

The  absolute  minimum  amount  of  radium  bromid  which 
Finzi  considers  efficacious  in  the  treatment  of  cancer  is  50  mg. 
He  now  uses  205  mg.,  with  which  amount  his  results  are  far 
more  promising  than  with  the  minimum  amount. 

Edling  ^  emphasizes  that  instead  of  the  so-called  massive 
doses  (20-30  eg.)  which  are  usually  not  available,  smaller  doses 
of  radium  salts  (2  eg.),  when  applied  for  a  sufficient  length  of 
time,  seem  to  accomplish  the  same  results.  Four  cases  of  in- 
operable carcinoma  of  the  uterine  cervix,  in  part,  with  involve- 
ment of  vagina  and  rectum,  were  treated  by  the  author  in  this 
manner.  Two  patients,  aged  36  and  56  years,  respectively, 
were  apparently  cured,  being  free  from  s^Tiiptoms  and  without 
a  tumor,  at  the  end  of  six  or  seven  months,  respectively.  Two 
other  very  far  advanced  cases  were  only  temporarily  improved. 

A  case  of  carcinoma  of  the  uterus,  with  myoma,  on  account 
of  severe  hemorrhage  and  extreme  anemia,  was  treated  with 
radium,  in  preparation  for  operation.  The  hemorrhage  sub- 
sided and,  nine  weeks  later,  a  total  extirpation  was  performed. 
Six  months  after  the  operation  the  patient  was  free  from  all 
symptoms. 

In  these  cases  Dominici  tubes,  with  2  eg.  radium  salt,  of  an 
activity  of  two  millions,  were  inserted  several  times,  at  inter- 
vals, into  the  cervix,  remaining  for  one  week  or  longer.  These 
tubes  give  off  an  ultra-penetrating  radiation,  composed  of  alpha 
rays  and  of  hard  beta  rays;  they  must  be  placed  in  gau^e- 
wrapped  draining  tubes  in  order  to  absorb  the  secondary  radia- 
tion, which  has  an  irritative  inflammatory  effect. 

Ledoux-Lebard  ^  strongly  recommends  the  use  of  injections 
of  sulphate  of  radium  in  inoperable  carcinoma  of  the  breast. 
The  dose  is  from  5  to  20  micrograms,  larger  doses  giving  no 
greater  relief.     The  injection  is  made  around  the  cancer. 

The  London  Radium  Institute  issued  its  first  scientific  re- 
port in  January,  1913,  covering  a  period  from  August  14, 
1911,  to  December  31,  1912.    During  this  time  657  cases,  both 

1  Edling,  L. — ' '  Radium  Treatment  of  Malignant  Tumors  of  the  Uterus, ' ' 
Nordisk.  Med.  Arlciv,  1911,  Vol.  44,  No.   16,  p.  1. 

2  Ledoux-Lebard. — Jour,  de  Eadiologie  de  la  Soc.  Beige,  1912,  p.  205. 


PHYSIOTHERAPY  303 

benign  and  malignant,  were  treated.     The  following  table  gives 
a  summary  of  the  results: 


Summari/. 


Examined  but  not  treated 38 

Recent  cases,  results  not  yet  noted 41 

Prophylactic  irradiation  only 39 

Apparently  cured 53 

Cured 28 

Improved 245 

Not  improved 70 

Abandoned  treatment 88 

Dead 55 

657 

There  were  134  cases  of  epithelioma  treated.  Of  this 
number  7  were  apparently  cured,  39  decidedly  improved,  22 
died,  20  showed  no  improvement,  23  abandoned  treatment,  15 
received  prophylactic  raying,  and  8  were  too  recent  to  be 
classified.  Of  all  the  malignant  conditions,  rodent  ulcer 
seemed  the  most  responsive  to  radium  irradiation.  The  Insti- 
tute reports  101  cases,  with  31  apparent  cures  and  12  uncured. 

The  histological  changes  which  appear  in  secondary  cancer 
nodules  treated  by  radium  have  been  studied  by  Dominici  and 
Rubens-Duval,  Delbert  and  Herrenschmidt,  Hastings,  MacCor- 
mac  and  Woodman,  and  others. 

It  has  been  estimated  (Wickham  and  Degrais)^  by  Sir  J.  J. 
Thompson  that  the  total  energy  liberated  by  a  milligram  of 
radium  during  its  radio-active  life  would  represent  nearly  a 
thousand  million  kilogrammeters,  and  Max  Abraham  has  cal- 
culated that  one  gram  of  electrons  (particles  liberated  in 
the  course  of  the  disintegration  of  matter)  would  represent 
the  energy  of  eighty  thousand  million  horse-power. 

If  these  calculations  be  correct,  it  seems  but  reasonable  to 
suppose  that  unless  extreme  care  be  exercised  in  the  utilization 
of  radium,  this  agent  may  be  productive  of  more  harm  than 
good — that  it  may  not  only  fail  to  retard  malignant  growth,  but 
may  accelerate  it,  and  even  cause  its  initiation.  With  this  idea, 
in  connection  with  studies  concerning  the  action  of  X-rays,  ura- 
nium and  thorium,  Lazarus-Barlow  ^  investigated  the  effect 
of  radium  in  the  experimental  production  of  cancer.  He  kept 
a  glass  tube  containing  radium  in  the  abdominal  cavity  of  a 

1  Pinch,  A.  E.  Hayward. — '  *  A  Report  of  the  Work  Carried  Out  at  the 
Radium  Institute,"  Brit.  Med.  Jour.,  January  25,  1913. 

2  See  "Radium  and  Cancer,"  1913,  p.  7. 

3  Lazarus-Barlow. — "Radio-activity  and  Carcinoma:  An  Experimental 
Inquiry,"  The  Croonian  Lectures,  Brit.  Med.  Jour.,  June  19  and  26,  1909, 
pp.  1465  and  1536. 


304  THE   CANCER   PROBLEM 

rabbit  for  months.  Ivabbits'  ears  were  exposed  to  the  rays  for 
prolonged  periods,  under  different  conditions.  The  results 
were  negative  as  regards  the  production  of  cancer. 

MESOTHORITJM 

It  has  been  said:  "Although  radium  itself  remains  at  fam- 
ine prices,  its  literature  is  increasingly  abundant.  We  extend 
vain  hands  of  supplication  for  milligrams  and  are  given — 
a  library."  This  state  of  affairs  has  led  to  many  investigations 
looking  to  the  discovery  of  a  radium  substitute  which  would 
be  within  the  reach  of  a  larger  number  of  clinicians,  while 
giving  equal  or  better  results  in  the  treatment  of  disease. 

With  this  end  in  view,  Ilahn  ^  has  worked  with  radiothor- 
ium,  in  an  endeavor  to  separate  it  from  the  thorium  minerals- 
Radiothorium,  which  emits  alpha  rays,  loses  half  its  activity 
in  two  years.  Hahn  found  that  the  alpha-ray  activity  of  thor- 
ium, after  separation,  decreased  at  first  for  some  years,  then 
slowly  increased  again  to  the  activity  of  a  pure  thorium  com- 
pound. From  this  he  concluded  that  there  must  be  another 
product  in  thorium  which  is  transformed  into  radiothorium. 
He  called  this  supposed  product  mesothorium.  The  half  value 
period  of  this  substance  is  about  five  and  a  half  years.  Meso- 
thorium does  not  emit  alpha  rays,  but  is  transformed  into 
radiothorium,  which  does  emit  them. 

Czerny  and  Caan  ^  investigated  the  treatment  of  malignant 
tumors  with  mesothorium  and  thorium  X.  Their  therapeutic 
experiments  comprise  altogether  120  cases,  including  85  car- 
cinomata,  12  sarcomata,  8  Ijinphosarcomata,  1  endothelioma, 
6  angiomata,  and  8  cases  of  tuberculosis,  lupus,  and  other  con- 
ditions. 

In  about  40  to  50  per  cent,  of  the  cases  a  favorable  effect 
of  the  mesothorium,  or  the  thorium  X,  respectively,  upon  the 
tumors  was  demonstrable.  This  effect,  although  sometimes 
rather  inconsiderable,  appears  nevertheless  noteworthy.  The 
clinical  material  consisted,  almost  without  exception,  of  well- 
advanced  cases,  in  which  no  cure,  but  only  a  slight  improve- 
ment, was  to  be  anticipated. 

The  experiments  would  seem  to  show  that  mesothorium  is 
at  least  equivalent  to  radium,  and  probably  superior  to  it  in 
the  treatment  of  superficial  tumors. 

1  Hahn,  O. — * '  Ein  neues  radioaktives  Element,  welches  Thoriumstrahlung- 
aussendet, ' '  Zeitschr.  f.  physiol.  Chemie,  Leipzig,  1905,  LI,  717.  Trans- 
lated  (abstract)   Chem.  News,  London,   1905,  XCI,  193. 

-  Czerny  and  Caan. — ' '  Ueber  die  Behandlung  bosartiger  Geschiilste  mit 
Mesothorium  und  Thorium  X,"  Miinch.  med.  Woch.,  1912,  No.  14,  p.  737. 


PHYSIOTHERAPY  305 

Pinkuss  ^  could  not  demonstrate  a  positive  curative  effect  in 
14  cases  of  cancer,  either  from  ingestion,  or  local  or  intrave- 
nous injection  of  thorium  X.  More  tangible  effects  followed 
upon  local  radiation  with  mesothorium-containing  capsules. 
His  observations  concerning  the  action  of  mesothorium  upon 
cancer  were  not  complete,  and  no  cured  case  could  be  placed  on 
record.  However,  he  suggested  the  use  of  mesothorium  radia- 
tion as  an  adjuvant  of  operative  measures,  or  as  a  substitute, 
when  surgical  interference  is  impossible.  Mesothorium  radia- 
tion is  equivalent  to  radium  radiation.  It  is  superior  to  Ront- 
gen  radiation  with  reference  to  the  deep  action,  the  "dosibil- 
itj,"  and  the  mode  of  application. 

The  most  remarkable  results  with  radium  and  mesothorium 
are  those  described  in  treatment  of  carcinoma  of  the  uterus  by 
Bumm.^  He  gives  a  brief  description  of  a  series  of  cases 
greatly  improved,  and  clinically  cured  at  the  time  of  writing. 
It  will  be  noted,  however,  that  sufficient  time  has  not  elapsed 
to  justify  the  use  of  the  word  "cure."  Pearce  Gould  ^  recently 
described  some  remarkable  immediate  results,  but  in  a  later 
letter  *  in  the  same  journal  he  stated  that  in  two  of  the  most 
striking  cases  the  improvement  had  not  been  maintained,  recur- 
rence had  taken  place,  and  a  lethal  issue  was  in  sight. 

Finally,  newspaper  readers  on  both  sides  of  the  Atlantic  are 
familiar  with  the  recent  sensational  statements  regarding  the 
huge  amount  of  radium  deposited  in  a  growth  of  the  shoulder 
of  a  well-known  Congressman,  but  which  were  followed  later  by 
the  news  of  his  death. 

RADIO-ACTIVE    GELATIN 

Various  radio-active  substances  have  been  utilized  in  the 
treatment  of  cancer.  Particular  attention  has  been  given  by 
some  to  radio-active  gelatin,  introduced  into  the  region  affected 
by  a  malignant  growth  after  its  removal,  for  the  purpose  of 
preventing  recurrence. 

It  may  be  well,  in  this  connection,  to  note  that  radium  and 
radio-active  substances  furnish  a  prolific  field  of  action  for 
quacks.^ 

1  Pinkuss,  A. — '  *  Zur  Mesothoriumtherapie  bei  Krebskranken, ' '  Berl. 
Min.   Woch.,  1912,  No.   20,  p.  935. 

2  Bmnm,  E. — * '  Ueber  die  Erf  olge  der  Rontgen-  und  Mesothoriumbestrah- 
lung  bei  Carcinom  der  weiblichen  Genitalen, "  Berl.  Min.  Woch.,  1913,  pp. 
1001   and  1033. 

3  Pearce  Gould,  Sir  Alfred. — ' '  An  Address  on  Eadium  and  Cancer, ' '  Brit. 
Med.  Jour.,  Jan.  3,  1914. 

HUd.,  Jan.  24,   1914. 
5  Nature,  April  30,   1913. 


306  THE  CANCER   PROBLEM 

In  view  of  the  large  number  of  drugs,  earths,  and  waters, 
said  to  be  radio-active,  being  offered  for  sale  to  the  general  pub- 
lic for  the  treatment  of  certain  diseases,  the  Medical  Committee 
of  the  British  Science  Guild  recently  instituted  an  inquiry  into 
the  question  of  radium  and  its  therapeutic  uses.^  The  result  of 
the  inquiry  indicates  the  urgent  necessity  for  legislation  in  or- 
der to  safeguard  the  interests  of  the  community  by  compelling 
a  written  giuiranty  to  be  given  as  to  the  quantity  of  radium 
present  in  the  substances  offered  for  sale. 

The  proposed  inclusion  of  radiimi  in  the  Pharmacopeia 
would  be  of  material  benefit  to  the  public.  It  has  also  been  sug- 
gested that  radiimi  should  be  scheduled  as  a  poison  under  the 
Food  and  Drug  Act.  This  would  be  an  additional  safeguard  to 
the  public. 

ELECTROCAUTERY    (Byrne  Method) 

The  electrocautery,  as  introduced  by  Middledorpf,  of  Bres- 
lau,  crude  as  it  was,  was  considered  by  many  surgeons  as  pref- 
erable to  destructive  chemical  agents  in  the  treatment  of  uterine 
cancer.  Conspicuous  among  its  advocates  was  the  late  Dr.  John 
Byrne,  of  Brooklyn,  who  so  adapted  and  improved  the  method 
that  it  has  come  to  be  known  as  the  Byrne  method  of  electro- 
cauterization.^ 

Byrne  considered  the  method  absolutely  free  from  danger, 
and  claimed  that  it  has  secured  for  sufferers  a  period  of  exemp- 
tion from  relapse  far  beyond,  and  in  startling  contrast  to  that 
of  hysterectomy. 

The  procedure  as  described  by  Byrne  is  as  follows:  First, 
all  softened  and  broken-down  tissue  is  removed  by  the  free  use 
of  a  sharp  curet.  The  cavity  is  repeatedly  sponged  with  a 
mixture  of  one  part  of  commercial  acetic  acid,  three  parts  of 
glycerin,  and  carbolic  acid  sufficient  to  represent  eight  per  cent, 
of  the  whole,  then  packed  with  absorbent  cotton,  which  is  al- 
lowed to  remain  for  a  few  minutes  or  longer  as  the  case  may  be. 
On  removing  this,  if  all  bleeding  is  found  to  have  ceased,  and 

1  The  report  of  this  committee  will  be  published  later. 

2  Byrne,  John. —  (1)  "Vaginal  Hysterectomy  and  High  Amputation,  or 
Partial  Extirpation  by  Galvano-cautery  in  Cancer  of  Cervix  Uteri.  An 
Inquiry  into  Their  Eelative  Merits,"  BrooMyn  Med.  Jour.,  November, 
1892. 

(2)  "A  Digest  of  Twenty  Years'  Experience  in  the  Treatment  of 
Uterine  Cancer  by  Galvano-cautery,"  Trans.  Am.  Gyn.  Soc,  Vol.  XIV, 
p.  91. 

(3)  "Rules  to  Be  Observed  in  Performing  High  Amputation  and  Other 
Operative  Measures  for  Cancer  of  the  Uterus  by  Galvano-cautery,"  Brook- 
lyn  Med.  Jour.,  November,  1892;  also:  International  System  of  Electro- 
therapeutics. 


PHYSIOTHERAPY  307 

the  cavity  is  dry,  cauterization  may  be  proceeded  with.  If, 
however,  oozing  of  blood  to  any  extent  should  continue,  it  will 
be  best  to  pass  into  the  cavity  a  properly  rolled  tampon  satur- 
ated with  the  above  styptic,  which  should  be  allowed  to  remain 
for  forty-eight  hours  before  the  application  of  the  cautery. 

The  cauterization  is  carried  out  in  the  following  manner: 
The  diseased  organ  is  exposed  to  view,  and  the  vagina  properly 
protected.  Before  introducing  the  cautery  electrode  a  wad  of 
absorbent  cotton  is  passed  into  the  cavity,  held  for  a  moment, 
and  immediately,  on  being  withdrawn,  the  cautery,  which  is 
brought  to  a  cherry-red  heat,  is  rapidly  and  repeatedly  passed 
over  the  bottom  of  the  cavity.  The  cavity  is  then  again 
dried,  and  cauterization  resumed  as  in  the  first  instance. 
This  process  is  repeated  over  and  over  until  the  deeper 
parts  of  the  cavity  have  become  dry  and  charred.  The 
sides  are  then  treated  in  precisely  the  same  manner,  and 
roasted  to  the  same  crisp  condition.  All  ragged  and  overhang- 
ing edges  are  next  trimmed  off  by  the  cautery  knife.  The 
cavity  is  then  firmly  packed,  and  a  supporting  vaginal  tampon 
inserted. 

After  this  preparation  the  high-amputation  is  executed  as 
follows :  "A  circular  incision  is  made,  the  cautery-knife,  which 
is  slightly  curved,  being  introduced  cold,  and  applied  close  up 
to  the  vaginal  junction.  The  current  is  turned  on  from  this 
instant,  the  knife  is  kept  in  contact  with  the  parts  being  in- 
cised. Current  cut  off  before  electrode  is  removed  for  any 
purpose.  Circular  incision  having  been  made  to  depth  of  say 
1/4  inch,  by  directing  the  knife  upward  and  inward  the  ampu- 
tation may  be  carried  to  any  extent." 

The  metallic  parts  of  the  electrode  for  about  two  inches  are 
covered  with  thin  flannel  to  protect  the  vagina. 

The  advantages  of  the  method,  as  stated  by  Byrne,  are  as 
follows:  "(1)  Absolute  freedom  from  danger,  immediate  or 
remote,  and  (2)  a  longer  respite  from  recurrence  of  the  disease 
than  has  yet  been  shown  by  the  most  favorable  and  ingeniously 
constructed  statistics  of  hysterectomy." 

Despite  the  success  which  Byrne  reported,  and  despite  the 
occasional  reported  success  of  others,  the  method  seems  to  have 
received  no  definite  recognition  from  the  surgical  world. 

Frederick  ^  has  recently  reported  the  successful  use  of  the 
method  for  five  years.  He  also  suggested  the  use  of  the  cau- 
tery, not  only  as  a  means  of  preparing  a  limited  number  of 
these  patients  for  later  radical  operation,  in  accordance  with 

1  Frederick,  Carlton  C. — ' '  Use  of  the  Cautery  in  Treatment  of  Carci- 
noma of  the  Cervix,"  Jour.  Am.  Med.  Assn.,  January  14,  1911,  p.  94. 


308  THE  CANCER   PROBLEM 

Byrne's  idea,  but  to  prevent  fresh  infection  of  the  raw  surfaces 
at  the  time  of  radical  operation, 

Massev  says,^  in  commenting  upon  Frederick's  paper: 
"This  paper  of  Dr.  Frederick's  is  a  belated  tribute  to  the  late 
Dr.  Byrne,  who  is  too  little  known  as  a  member  of  the  Royal 
Chirurgical  Society  of  Edinboro,  former  president  of  the 
American  Gynecological  Society,  and  author  of  the  section  on 
Electro-thermal  Surgery  in  the  Bigelow-Massey  'International 
System  of  Electro-Therapeutics.'  It  is  a  sad  comment  on  con- 
temporary surgery,  and  its  tendency  to  a  blind  adherence  to 
prevailing  fashions,  that  the  radical  teachings  of  this  forceful 
man  were  absolutely  neglected  during  his  lifetime." 

In  my  own  experience  the  number  of  cases  in  which  the 
Byrne  method  is  indicated  has  been  lessened  by  the  Wertheim 
method,  arterial  ligation,"  and  other  measures  for  the  treat- 
ment of  uterine  cancer. 

Percy  ^  has  reported  the  use  of  the  electrocautery,  baaing 
his  application  of  this  agent  upon  the  ^^time-immemorial  fact" 
that  high  degrees  of  heat  retard  malignant  growths  on  the  sur- 
face of  the  body,  as  demonstrated  by  Leo  Loeb,*  Lambert,^  and 
others.  He  has  applied  his  method  in  inoperable  cases  in 
which  he  considers  that  either  the  Byrne  or  the  Ries-Wertheim 
operation  would  be  "utter  foolishness."  One  of  the  benefits 
which  he  emphasizes,  following  the  application  of  heat,  is  the 
apparent  lessened  virulence  of  metastases. 

HIGH-FREaUENCY    CURRENT 

It  would  be  impossible,  in  a  work  of  this  character,  to  enter 
into  details  concerning  the  different  electric  currents  and  the 
various  methods  of  applying  each.  Among  them  great  prom- 
inence has  been  given  to  the  high-frequency  current,  which  is 
now  being  so  variously  employed  in  the  treatment  of  malignant 
neoplasms. 

Credit  is  accorded  to  Riviere,  of  Paris,  for  inaugurating  the 

1  Betton-Massey,  G. — ' '  Gynecology  and  Electro-chemical  Surgery, ' '  Jour- 
nal of  Advanced   TJierapeutics,   March,   1911,  p.   139. 

2  See  "Arterial  Ligation"  (Section  XI,  Chap.  2),  and  "Irremovable 
Cancer"   (Section  XII). 

3  Percy,  J.  F. — ' '  A  Method  of  Applying  Heat  Both  to  Inhibit  and 
Destroy  Inoperable  Carcinoma  of  the  Uterus  and  Vagina,"  Surg.,  Gyn. 
and  Obst.,  September,  1913,  p.  371. 

■i  See  Percy. — ' '  The  Eesults  of  the  Treatment  of  Cancer  of  the  Uterus 
by  the  Actual  Cautery,  with  a  Practical  Method  of  Its  Application,"  Jour. 
Am.  Med.  Assn.,  1912,  Iviii,  696. 

5  Lambert,  Eobert  A. — ' '  Demonstration  of  the  Greater  Susceptibility  to 
Heat  of  Sarcoma  Cells  as  Compared  with  Actively  Proliferating  Connec- 
tive Tissue  Cells,"  Jour.  Am.  Med.  Assn.,  December  14,  1912,  p.  2147. 


PHYSIOTHERAPY  309 

application  of  high-frequency  discharge  from  a  metal  point 
with  a  current  of  sufficient  energy  to  destroy  living  tissue. 
Following  his  lead,  a  number  of  methods  now  claim  attention^ 
the  originator  of  each  maintaining  certain  points  of  difference 
from  the  original  and  from  other  subsequent  methods.  The 
various  methods  are  discussed  briefly  in  the  pages  which  follow. 

ALTO-FHEaUENT   CYTOLYSIS,  ALTO-r»EaTJENT   SCINTILLATION, 
EFFLETJVATION,  ETC.  (Riviere)  i 

The  Riviere  method  of  treating  malignant  tumors  by  high- 
frequency  sparking  and  effleuve  was  first  described  in  1900. 
The  term  fulguration,  he  declares,  was  subsequently  applied 
to  the  method,  but  not  accepted  by  him  as  a  designation  for  it. 
His  conclusions  at  that  time  were  that  "high-frequency  cur- 
rents appeared  to  cure  small  facial  epitheliomata  and  to  exer- 
cise, in  certain  cases,  a  beneficial  influence  on  the  evolution  of 
some  malignant  tumors.  They  first  produce  a  thermo-elec- 
trical'chemical  action,  the  effect  of  which  is  to  eliminate  neo- 
plastic tissues  and,  if  we  admit  the  parasitic  theory,  to  destroy 
micro-organisms  and  their  toxins;  and,  in  the  second  place,  they 
produce  a  tropho-neurotic  curative  action,  which  brings  bach 
the  vital  processes  to  the  normal  state. 

"It  could  not  be  a  contemplation  to  employ  the  thermo-elec- 
trical-chemical  action  for  the  elimination  of  large  tumors,  for 
which  excision  is  the  elective  treatment,  but  the  surgical  opera- 
tion should  be  followed  by  the  preventive  and  curative  treat- 
Tnent  in  recurrent  cases. 

"High-frequency  currents  and,  more  especially,  the  monopolar 
e'ffleuves  of  Oudin's  resonator,  seem,  to  exercise  this  action  by 
modifying  the  vitality  of  the  new  regions  contaminated  hy  the 
surgeon's  knife  during  the  operation,  after  having  drained  and 
disinfected  them..  This  special  mode  of  applying  electricity 
seems,  at  the  present  time,  one  of  the  only  therapeutical  meth- 
ods to  be  tried  in  cases  of  inoperable  tumors." 

Eiviere  reviewed  the  subject  in  1909,  asserting  that  since 
1900  he  had  maintained  that  "every  operation  for  malignant 
growths  should  be  immediately  followed  by  the  application  of 
high-frequency  sparks  and  effleuves,  in  order  to  avoid  contam- 

1  Riviere,  J.  A. — ' '  Action  of  High  Frequency  Currents  and  of  the 
Effleuves  of  Oudin's  Eesonator  on  Certain  Malignant  Tumors  and  on 
Tuberculosis,"  First  International  Congress  on  Medical  Eleetrology  and 
Eadiology,  Paris,   1900. 

Also:  "Alto-Frequent  Cytolysis  of  Cancer." — Jour,  of  Advanced 
Therapeutics,   1909,   pp.  337,  380,  and  434. 

Also:  "Esquisses  Cliniques  de  Physieotherapie — Traitement  rational 
des  maladies  chroniques, "   Paris,   1910. 


310  THE  CANCER   PROBLEM 

ination  of  the  open  surgical  wound  and  to  prevent  recurrence." 
He  declared  that  by  means  of  different  electrodes  he  could  pass 
from  the  very  finest  shower  of  sparks  (eflieuves)  to  well-nour- 
ished short  sparks  (4  to  5  centimeters),  and  even  to  sparks  and 
effleuves  of  from  5  to  15  centimeters  in  length.  He  insisted 
that  the  method  of  de  Keating-Hart,  to  which  the  term  fulgura- 
tion  has  been  applied,  had  added  nothing  to  the  Riviere  method 
except  the  ''useless  spraying,  or  blowing,  of  air"  through  the 
electrode.  (See  Fulguration,  p.  313.)  Kiviere  did  not  agree 
that  the  high  voltage  claimed  for  the  de  Keating-Hart  method 
was  correct,  but  that  on  the  contrary  the  voltage  was  low  and 
the  amperage  high,  just  as  in  the  Riviere  method. 

"DESTRUCTIVE    FULGURATION" 

The  term  "destructive  fulguration"  is  sometimes  employed 
to  designate  the  method  as  usually  employed  by  Riviere,  and 
as  it  has  been  used  by  many  surgeons  and  electrotherapeutists, 
viz.,  the  destruction  of  malignant  neoplasms  by  means  of  cur- 
rents of  high  frequency,  with  short,  low-tension  sparks.  To 
this  method  is  frequently  applied  the  term  electrocauteriza- 
tion,  or  "burning  down."  Destructive  fulguration  has  been 
very  frequently  confounded  with  the  fulguration  method  of  de 
Keating-Hart,  which  is  in  no  sense,  according  to  its  originator, 
a  destructive  or  burning  method. 

FULGURATION    (de   Zeating-Hart) 

One  of  the  world's  greatest  philosophers  has  said:  "There 
is  a  principle  which  is  a  bar  against  all  progress,  and  which 
cannot  fail  to  keep  a  man  in  everlasting  ignorance;  this  prin- 
ciple is  contempt  prior  to  examination."  It  is  the  desire  of 
every  seeker  after  truth  to  avoid  this  deadly  principle,  to  ex- 
amine first,  and  then  to  accept  with  approval,  or  to  reject  with 
contempt.  If  examination  is  impossible,  suspended  judgment 
is  in  order. 

The  Committee  on  Scientific  Research  of  the  New  York 
Skin  and  Cancer  Hospital  has  borne  this  principle  in  mind  in 
its  study  of  the  cancer  problem,  being  willing  at  all  times  to 
investigate  the  claims  of  any  method  for  the  palliation  or  cure 
of  malignant  neoplasms,  providing,  of  course,  that  such  investi- 
gation presents  no  element  of  danger  to  the  well-being  of  the 
patient  concerned. 

Accordingly,  when,  about  five  years  ago,  our  attention  was 
first  directed  to  the  treatment  of  cancer  by  the  de  Keating-Hart 


PHYSIOTHERAPY  311 

method  of  "fulguration,"  or  "sideration,"  as  it  was  then  called, 
it  was  decided  to  investigate  the  theory  upon  which  it  was 
based,  as  well  as  the  technic  of  its  application,  and,  if  re- 
sults warranted  it,  to  give  the  method  a  scientific  trial  in  a 
series  of  cases. 

During  various  trips  to  Europe,  I  visited  Dr.  de  Keating- 
Hart,  who  demonstrated  his  apparatus  and  explained  his 
method  in  detail.  I  saw  him  employ  fulguration  in  numbers 
of  cases,  and  examined  many  of  the  patients  previous  to  opera- 
tion, as  well  as  upon  successive  visits  afterward. 

In  some  of  the  cases  the  cure  of  the  cancer  does  not  offer  in 
itself  any  special  interest,  since  this  might  have  been  obtained, 
as  de  Keating-Hart  has  pointed  out,  at  least  in  the  first  group,  by 
a  number  of  well-known  means.  The  cases  are  of  real  signifi- 
cance only  when  considered  from  a  triple  point  of  view : 

(1)  The  strictly  limited  eradication  of  tissue  around  the 
lesions,  thus  saving  or  lessening  subsequent  deformity. 

(2)  The  non-recurrence  obtained  for  a  number  of  years,  al- 
though in  certain  cases  the  disease  had  not  been  checked  by 
other  means;  or,  in  primary  cases,  the  lessened  likelihood  of 
recurrence. 

(3)  The  relatively  slight  disfigurement  produced  by  the 
method  in  the  cases  presented. 

These  cases  are  all  a  matter  of  record,  and  are  reproduced 
here  merely  for  purposes  of  interest  and  emphasis.  It  may  be 
said,  in  justice  to  de  Keating-Hart  and  his  method,  that  these 
cases  represent  patients  of  sufficiently  varied  ages  and  disease 
of  sufficient  severity  to  give  to  them  an  undeniable  value. 
Each  has  undergone  careful  histological  examination,  and  in 
the  published  works  of  de  Keating-Hart  may  be  found  the 
names  of  physicians  and  surgeons  by  whom  the  patients  were 
treated,  as  well  as  the  names  of  the  laboratories  where  micro- 
scopic examinations  were  made. 

As  the  months  passed  and  de  Keating-Hart's  reports  con- 
tinued favorable,  as  did  likewise  those  of  a  number  of  other 
European  investigators,  our  interest  was  still  further  aroused 
in  the  method. 

Desplat,  appointed  by  the  French  Association  for  the  Ad- 
vancement of  Science  to  report  upon  "the  remote  results  of  ful- 
guration in  the  treatment  of  cancer"  (Congress  at  Toulouse, 
August,  1910),  cited  a  number  of  interesting  cases  published 
by  Dubois-Trepagne  and  himself.  He  concludes  his  report 
with  the  following :  "After  three  years'  experience,  I  conclude, 
as  I  concluded  after  the  first  year:  that  fulguration  has  en- 
larged considerably  the  field  of  surgery  in  giving  it  marked 


312  THE   CANCER    PROBLEM 

chances  of  success  in  those  cases  where  it  previously  dared  no 
longer  intervene,  and  I  now  reply  positively  to  the  question 
which  I  had  left  under  judgment  for  two  years,  that  fulguration 
gives  the  patient  chances  of  prolonged  non-recurrence  superior 
to  those  chiinces  which  surgery  gives  when  left  to  itself  alone." 

Segond,  who  declared  himself,  at  the  International  Confer- 
ence,on  Cancer  in  Paris,  in  October,  1910,  as  being  against 
the  method,  said  of  it,  fulguration  ''has  increased  their  resist- 
ance and  prolonged  their  lives,  transformed  or  cicatrized,  in 
praiseworthy  fashion,  horrible,  bleeding  areas  which  tortured" 
patients  whose  pain  nothing  would  calm.  "Fulguration,"  he 
said,  "permits  surgery  to  intervene  where  intervention  was  no 
longer  possible,  and  may  offer  a  chance  of  non-recurrence  to 
those  cases  which  surgery  alone  cannot  relieve." 

Such  statements,  reinforced  by  our  own  observations,  en- 
couraged us,  despite  the  unfavorable  reports  which  from  time 
to  time  appeared,  to  install  a  de  Keating-Hart  fulguration  ap- 
paratus at  the  New  York  Skin  and  Cancer  Hospital,  and  to 
extend  to  Dr.  de  Keating-Hart  an  invitation  to  visit  New  York 
and  personally  demonstrate  the  apparatus  and  explain  the  the- 
ories upon  which  his  method  of  fulguration  is  based. 

The  apparatus,  which  had  been  constructed  under  Dr.  de  Keat- 
ing-Hart's personal  direction,  was  installed  in  the  hospital  in 
November,  1911,  and  in  December  he  visited  America,  giving 
a  series  of  demonstrations  at  the  New  York  Skin  and  Cancer 
Hospital,  and  delivering  a  number  of  lectures  in  other  cities. 
Invitations  were  extended  to  many  of  the  leading  surgeons  in 
this  country  and  Canada  to  attend  these  demonstrations,  and 
the  operating  room  was  taxed  to  its  utmost  capacity  each  day 
by  members  of  the  medical  profession  who  seemed  eager  to  wit- 
ness the  fulguration  "seances,"  as  the  originator  of  the  method 
is  wont  to  call  the  applications  of  fulguration. 

Many  cases  of  cancer,  in  various  stages  of  operability,  were 
treated  during  the  nineteen  days  of  Dr.  de  Keating-Hart's  visit. 
The  surgical  operations  were  performed  by  the  author,  with  the 
assistance  of  Dr.  Franz  Torek,  Dr.  E.  M.  Foote,  and  other 
members  of  the  hospital  staff.  Dr.  de  Keating-Hart  was  as- 
sisted in  the  instrumentation  by  Dr.  Worthington  S.  Russell, 
in  charge  of  the  electrotherapeutic  department  of  the  hospital. 

histrumentation  and  Technic. — The  production  of  ful- 
guration sparks  may  be  accomplished  by  means  of  very  differ- 
ently adjusted  apparatus.  The  following  list  comprises  the 
equipment  to  which  de  Keating-Hart  gives  preference: 

(1)  Electric  source:  city  current,  dynamos,  or  accumula- 
tors, etc. 


PHYSIOTHERAPY  313 

(2)  A  table  holding  tho  rheostats,  amperemeters,  etc. 

(3)  A  transformer  coil  with  rapid  interrupter,  or  trans- 
former in  the  closed  magnetic  circuit  (alternating  current). 

(4)  A  condenser  furnished  with  a  spark  gap. 

(5)  Ou din's  resonator. 

(6)  A  bellows  furnished,  according  to  the  case,  with  a  foot- 
pedal,  or  with  a  tube  of  carbonic  acid,  or  an  electric  bellows 
with  disinfected  air. 

(7)  Special  electrodes  of  de  Keating-Hart. 

(8)  An  operating  table  of  wood  or  metal. 
A  few  details  to  be  emphasized: 

(1)  The  source  of  the  current  must  be  powerful. 

(2)  The  amperage  at  the  primary  may  vary  enormously 
(from  two  to  eight  or  ten  amperes,  according  to  the  voltage  of 
the  current,  and  the  manner  in  which  it  is  utilized  by  the  in- 
ternal construction  of  the  coil,  etc.). 

(3)  The  length  of  the  coil  cannot  be  measured  in  terms  of 
the  length  of  the  spark,  as  formerly,  because  of  important  modi- 
fications which  have  been  introduced  in  the  internal  adjust- 
ment of  the  new  apparatus.  In  the  old  models  one  was  able 
to  estimate  a  minimum  of  forty  to  forty-five  centimeters  of 
spark  as  the  limit  of  the  secondary.  But  the  ensemble  of  the 
apparatus  ought  to  be  able  to  produce,  at  the  extremity  of  the 
solenoid  of  the  resonator,  crackling  white  sparks  of  a  mini- 
mum length  of  from  seven  to  eight  centimeters. 

(4)  The  electrode,  the  special  instrument  for  delivering  the 
spark  to  the  patient,  is  in  the  form  of  a  sound.  It  is  made  of  a 
smooth,  metallic  mandrel,  or  obturator,  working  snugly  within 
an  insulated  tube  of  hard  rubber. 

(5)  The  bellows  produced  during  the  operation  a  constant 
circulation  within  the  hard  rubber  tube  of  a  current  of  carbon 
dioxid,  or,  preferably,  of  air,  the  purpose  of  which  is  twofold: 
1,  to  prevent  a  rise  in  temperature  of  the  column  of  air  within 
the  electrode  where  the  sparks  are  produced;  2,  to  remove  the 
coagulable  liquids  which  may  obstruct  the  free  end  of  the 
sound  at  points  of  contact  of  the  latter  with  the  operative  field. 

(6)  This  gaseous  circulation  first  strikes  the  upper  end  of 
the  sound  and  escapes  at  the  tip.  An  electric  contact  is  then 
established  between  the  electric  source  and  the  metallic  man- 
drel. The  mandrel  is  then  withdrawn  from  ten  to  twelve  centi- 
meters outside  of  its  hard  rubber  casing,  in  such  a  way  that  the 
point  of  the  conductor  is  situated  at  an  equal  distance  from  the 
tip  of  the  insulated  sound.  Consequently,  in  order  to  reach  the 
fulgurated  zone,  the  spark  must  pass  through  the  non-conduct- 
ing aerial  column  in  the  sound,  which  will  permit  the  operator 


314  THE   CANCER   PROBLEM 

to  deliver  sparks  to  those  parts  only  which  it  is  intended  to 
reach.  For  a  large,  flat  surface,  such  an  instrument  may  not 
be  necessary.  In  all  hollow  places,  or  in  all  empty  organs,  a 
spark  which  is  not  thus  surrounded  by  insulation  spends  itself 
upon  the  edges  or  upon  certain  points  and  cannot  penetrate  in 
its  entire  length  to  the  bottom  of  the  place  in  question. 

(7)  Even  with  this  instrument,  perfected  as  it  is,  one  is 
not  free  from  all  error  of  technic  unless  it  be  utilized  ac- 
cording to  certain  principles  and  with  extreme  care.  The  first 
precaution  is  the  surveillance  of  the  proper  functioning  of  the 
apparatus.  If  the  interior  wall  of  the  hard  rubber  tube  is  still 
moist  after  being  sterilized,  it  may  change  completely  the  prop- 
erties of  the  spark,  especially  its  length,  by  prolonging  the 
metal  conductor  through  a  conducting  liquid  as  far  as  the  in- 
ferior extremity  of  the  instrument.  Likewise,  it  may  happen 
that,  in  spite  of  the  bellows,  or,  at  least  through  its  insufficiency, 
a  coagulum  may  fill  up  the  interior  of  the  electrode,  altering 
the  force  and  the  quantity  of  the  current. 

It  would  take  too  long  to  discuss  here  all  the  incidents  which 
may  take  place  in  the  course  of  fulguration,  and,  by  changing 
the  entire  conditions,  vitiate  the  results.  From  the  foregoing 
it  may  be  readily  inferred  that  precision  of  technic  is  quite 
as  essential  in  the  application  of  the  electrical  current  as  it  is 
in  the  preceding  surgical  operation. 

Surgical  Technic. — The  first  step  of  fulguration  is  purely 
surgical.  This  depends  entirely  upon  the  exigencies  of  the 
case,  and  need  not  be  given  detailed  consideration  here.  Ful- 
guration is  essentially  a  method  of  treatment  for  operable  can- 
cers. The  more  complete  the  removal  of  diseased  tissue,  the 
more  certain,  according  to  de  Keating-Hart,  is  the  freedom 
from  recurrence.  The  possibility  of  complete  cure  and  ab- 
solute prevention  of  recurrence  is  commensurate  with  the  ex- 
tent to  which  eradication  may  be  carried.  Where  only  partial 
removal  of  diseased  tissue  is  possible  the  method  of  fulguration 
is  palliative  rather  than  curative.  In  these  cases  de  Keating- 
Hart  advocates  another  method — thermoradiotherapy  (see 
page  317. 

Electrical  Technic. — The  electrical  technic  is  simple  in  its 
description  and  delicate  in  its  application.  The  general  rule 
laid  down  by  de  Keating-Hart  is  as  follows :  Spark  for  a  long 
time,  using  powerful  sparks  of  high  frequency  and  high  ten- 
sion, applying  them  to  the  area  from  which  every  macroscopic 
trace  of  cancer  has  been  removed.  It  is,  then,  under  the  cancer, 
and  not  upon  it,  that  the  electrical  discharge  is  applied. 

The  spark  should  be  white,  producing  the  sensation  of  a  vio- 


PHYSIOTHERAPY  315 

lent  shock,  its  mean  length  to  be  from  ten  to  twelve  centi- 
meters. An  important  detail  is  the  utilization  of  the  spark  at 
its  maximum  length.  The  electrode  should  be  kept  in  constant 
motion,  and  should  be  regularly  passed  over  the  surface  being 
treated.  The  reason  for  this  is  twofold:  (1)  In  order  to  avoid 
carbonization  of  the  points  at  which  the  spark  strikes  the  tissue ; 
(2)  in  order  to  equalize  the  dosage,  save  at  suspected  points 
where  one  must  work  energetically. 

It  is  impossible  to  establish  the  dosage,  or  the  duration  of 
the  application  of  the  spark  upon  a  given  point,  in  other  than 
an  empirical  manner.  It  is  not  difficult  to  comprehend  the 
reason  for  this,  when  one  realizes  that  no  two  machines  are 
exactly  alike,  and  that  in  the  same  apparatus  there  may  be 
great  variations  in  the  primary  current,  the  distance  of  the 
spark-gap,  and  the  conductibility  of  the  air  which  surrounds  it, 
all  of  which  have  an  influence,  as  does  likewise  the  insulation 
of  the  patient.  Under  such  conditions  the  electrical  properties 
of  the  spark  are  subject  to  enormous  variation.  As  a  general 
rule,  however,  one  may  advise  ''ten  minutes  of  fulguration  for 
an  area  of  ten  square  centimeters."  This  is  near  enough  for 
ordinary  purposes,  in  the  majority  of  cases,  and  with  the  usual 
apparatus. 

Another  guide  in  the  matter  of  duration  is  the  change  in  the 
color  of  the  tissue  being  fulgurated.  All  tissues  take  on  a 
slightly  darker  tinge,  not  from  destruction,  but  from  the  de- 
posit of  small  blood  clots  produced  at  the  surface  through  con- 
tact with  the  spark.  This  change  of  color  varies  with  the  tissue 
involved.  While  the  muscles  take  on  the  tinge  of  smoked  meat, 
the  bones  become  slightly  yellow.  In  reality  these  appearances 
are  apt  to  be  deceptive,  depending  upon  the  manner  in  which 
the  sparking  is  carried  out,  and  upon  the  thickness  of  the 
sanguinolent  fluid  through  which  it  passes.  As  a  rule,  bones 
should  not  be  fulgurated  as  long  as  the  muscles,  or  the  vessels 
as  long  as  the  tendons. 

The  two  main  points  to  be  emphasized  are:  (1)  Sufficient 
removal  of  diseased  tissue;  (2)  powerful  sparking  of  the  un- 
derlying tissues. 

The  method  should  not  be  condemned  unless  these  two  essen- 
tial features  are  practiced.  De  Keating-Hart  calls  attention  to 
the  fact  that  most  of  the  German  authors,  with  the  notable 
exception  of  Czerny,  have  published  only  failures.  This  is 
accounted  for,  in  his  judgment,  by  the  fact  that  almost  every- 
where in  Germany  he  has  seen  very  defective  electrodes  em- 
ployed. The  apparatus  in  these  instances  permits  of  the  use 
of  a  spark  only  about  three  centimeters  long.     Furthermore, 


316  THE   CAN'CER   PROBLEM 

this  spark  fails  to  affect  the  parts  concerned  when  one  is  work- 
ing at  the  bottom  of  a  cavity. 

Bad  instrumentation  and  bad  technic,  combined  with  in- 
complete surgical  intervention,  are  the  chief  causes  of  failure. 
In  addition  to  these,  an  improper  understanding  of  the  indica- 
tions for  fulguration  may  lead  to  failure.  Some  tumors,  be- 
cause of  their  location  (as  in  the  intestines,  uterus,  brain, 
lung),  escape  the  action  of  the  spark.  In  such  cases  fulgura- 
tion alone  is  not  indicated,  but  ^'thermoradiotherapy,"  another 
method  suggested  by  de  Keating-Hart,  of  which  we  will  speak 
later. 

Theoretical  Basis  of  Fulguration.  —During  the  visit  of  Dr.  de 
Keating-llart  to  this  country  full  notes  were  taken  of  his  lec- 
tures and  demonstrations,  in  order  that  our  test  of  his  method 
might  be  in  absolute  accord  with  his  views.  In  addition  to 
this,  he  was  asked  to  formulate  for  us  a  full  exposition  of  the 
theory  upon  which  he  bases  his  claims  concerning  fulguration. 
T\liat  is  said  here  on  the  subject,  therefore,  is  an  abstract  of 
his  own  statements.  We  wish  to  emphasize  the  fact  that  we 
are  neither  accepting  nor  rejecting  his  views,  but  that,  as  stated 
in  the  beginning,  we  are  merely  examining  the  evidence  by 
clinical  tests. 

The  premise  upon  which  the  de  Keating-Hart  fulguration 
method  has  been  developed  is  that  the  unipolar  long  sparh  of 
high  frequency  and  high  tension  acts,  not  upon  the  neoplasms, 
hut  upon  the  soil  on  which  the  neoplasm  has  developed. 

Three  gTOups  of  facts  are  relied  upon  to  establish  the 
premise. 

(1)  That  sparking,  even  when  used  with  inadequate  surgi- 
cal operation,  gives  undeniable  results,  insufficient,  doubtless, 
but  already  very  definite. 

(2)  That  the  tumor  is  in  no  way  modified  in  its  appear- 
ance or  in  its  vitality,  from  which  one  may  reasonably  conclude 
that  it  is  not  the  tumor  itself,  but  the  condition  of  its  nutrition 
— that  is  to  say,  the  environment  in  which  it  develops — that  is 
transformed. 

(3)  That  laboratory  experiments  and  clinical  observations 
furnish  plausible  explanations  of  the  foregoing. 

THERMOPENETRATION    (d'Arsonval) 

In  1896  d'Arsonval  demonstrated  the  power  of  the  high- 
frequency  current  to  cause  a  decided  rise  of  temperature  in 
tissues  interposed  between  two  electrodes.  This  property  of 
thermopenetration  has  been  variously  utilized  by  different  in- 


PHYSIOTHERAPY  317 

vestigators  in  tho  treatment  of  cancer.  By  some,  notably  de 
Keating-Hart,  it  has  been  employed  for  the  purpose  of  heating 
the  tissues  with  a  view  to  rendering  them  more  radiosensitive; 
by  others  (ISTagelschmidt  and  Doyen)  it  has  been  used  as  a 
means  of  destruction  of  neoplasms. 

THERMORADIOTHERAPY    (de   Keating-Hart) 

The  method  to  which  its  originator,  de  Keating-Hart,  ap- 
plied the  term  thennoradiotherapy  consists,  briefly,  in  sensitiz- 
ing the  tissues  by  fulguration,  or  other  means,  and  their  irradia- 
tion by  means  of  X-rays,  the  skin  surface  through  which  the 
X-rays  must  pass  being  previously  or  simultaneously  cooled  in 
order  to  prevent  X-ray  dermatitis. 

Theory.- — De  Keating-Hart's  theory,  upon  which  the  method 
of  thermoradiotherapy  is  based,  is  as  follows :  ^ 'Every  lumi- 
nous radiation  passing  through  a  living  organism,  determines  in 
it  biochemical  reactions,  the  intensity  of  which  varies  with  the 
quantity  and  duration  of  the  exposure  from  a  mere  over-excite- 
ment of  normal  transformation  to  the  destruction  of  cell-life. 
Such  is  the  law  regulating  the  relations  of  living  beings  to  light, 
whatever  the  length  of  the  luminous  vibrations. 

"It  must  not  be  overlooked,  however,  that  a  knowledge  of  the 
quantity,  number,  and  duration  of  irradiations  does  not  neces- 
sarily imply  a  knowledge  of  the  length  and  intensity  of  bio- 
chemical reactions. 

"The  explanation  of  the  unequal  effects  produced  by  radia- 
tions of  the  same  strength  must  be  sought  in  the  morphological 
differences  and  the  biological  state  of  the  cells  themselves  at  the 
moment. 

"Every  radiotherapeutist,  however  expert  he  may  be,  and 
even  with  the  use  of  the  same  instrumentation  under  the  same 
general  conditions,  sees  very  different  results  according  to  the 
individual.  It  is  well  known  that  certain  pathological  tissues 
are  much  more  sensitive  than  others  to  Rontgen  rays. 

"In  1907  Bergonie  and  Tribondeau  (of  Bordeaux)  threw 
some  light  on  these  hitherto  empiric  notions.  Their  researches 
were  made  to  determine  the  amount  of  cell  destruction  in  the 
organic  depths  with  radiations  which  were  innocuous  to  sur- 
rounding or  more  superficial  tissues.  From  their  work  these 
authors  have  arrived  at  certain  conclusions  which,  if  not  suffi- 
cient to  explain  all  known  facts,  permit  one  to  understand  at 
least  many  important  phenomena. 

"The  following  three  laws  are  worth  remembering:  The 
activity  of  rays  is  proportional:     First,  to  the  reproductive 


318  THE   CANCER   PROBLEM 

activity  of  the  cells;  second,  to  the  duration  and  constancy  of 
their  karyokinetic  movements ;  third,  to  the  higher  differentia- 
tion of  cell  morphology  and  function. 

"From  these  data  we  may  readily  conclude  that  the  effect  of 
X-rays  on  pathological  cells  is  not  specific.  It  is  thus  easily 
understood  how  neoplasms  are  destroyed  by  X-rays  that  pass 
through  the  more  fixed  normal  cells.  For  the  same  reason 
certain  tumors  of  rapid  growth  are  more  radiosensitive  than 
tumors  characterized  by  less  constant  and  intensive  karyo- 
kinesis. 

"Of  a  similar  nature  are  the  conclusions  drawn  by  Dominici 
and  Cheron  from  radium  effects.  These  experimenters  not  only 
observed  a  greater  radium-fragility  in  the  case  of  epitheliomata 
than  in  that  of  sarcomata,  but  they  noted  also  the  same  differ- 
ence between  embryonic  sarcomata  and  fibrochondro-sarcomata, 
the  cells  and  functions  of  which  are  more  especially  differenti- 
ated. 

"In  the  same  way  also  Schwartze  observed  that  moistened 
and  sprouting  seeds  are  more  radiosensitive  than  those  which 
are  previously  dried.  In  this  we  have  an  obvious  confirmation 
of  Bergonie's  findings. 

"On  the  other  hand,  these  laws  do  not  by  themselves  explain 
the  great  skin-sensitiveness  from  which  certain  patients  suffer 
during  every  exposure  to  X-rays,  no  matter  how  short  the  sit- 
ting may  be. 

"Furthermore,  these  laws  do  not  explain  the  resistance  of- 
fered to  the  Rontgen  rays  by  certain  tumors  which  were  in 
the  very  beginning  of  treatment  markedly  radiosensitive.  This 
is  still  more  remarkable  when  we  remember  that  cutaneous 
tissue  becomes  weaker  at  every  successive  radiotherapeutic  sit- 
ting. 

"Another  contradictory  fact  was  observed  by  Gerhartz :  that 
the  genital  organs  of  frogs  (organs,  however,  made  up  of  karyo- 
kinetic cells)  were  not  found  to  be  sensitive  to  the  X-rays. 
This  would  appear  to  be  contrary  to  Bergonie's  rule  and 
to  the  conclusion  drawn  from  Schwartze's  experiments  on 
seeds. 

"Paul  Becquerel,  upon  exposing  dried  spores  of  yeast,  found 
that  these  spores  are  very  quickly  sterilized  at  normal  tempera- 
ture and  but  very  slowly  when  frozen. 

"When  we  consider  that  the  experiments  of  Gerhartz  were 
made  during  the  winter  on  frogs,  animals  whose  temperature 
is  variable,  we  can  only  conclude  that,  as  in  Becquerel's  experi- 
ments, cold  seems  to  be  opposed  to  the  destructive  action  of  rays 
on  living  cells. 


PHYSIOTHERAPY  319 

"Histopathology,  clinical  researches,  and  personal  experi- 
ence have  confirmed  the  statement  that  I  made  at  the  Dijon 
Congress,  namely,  other  conditions  being  equal,  the  radiosensi- 
tiveness  of  tissues  depends  upon  their  temperature.  In  other 
words,  the  higher  the  temperature  of  tissues  (between  the 
normal  vital  limits)  the  greater  the  destructive  power  of  radia- 
tion upon  them." 

Technic. — Thermoradiotherapy  is  applied  in  three  ways, 
as  follows : 

(1)  In  the  case  of  tumors  with  abundant  blood  supply, 
such  as  sarcomata,  physiological  hot  serum  is  injected  at  50° 
C,  and  in  such  quantity  as  to  raise  the  internal  temperature  of 
the  neoplasm  to  about  41°  or  42°  0. 

(2)  In  cases  of  cancer  developed  in  the  natural  cavities 
(rectum,  vagina,  stomach)  irrigations  as  warm  as  possible  are 
used  during  a  time  varying  with  the  needs  of  the  individual 
case. 

(3)  In  tumors  of  a  woody  consistency,  that  can  be  heated 
neither  by  injection  nor  irrigation,  high-frequency  currents 
are  employed  either  by  passing  the  current  through  needles 
thrust  into  the  skin,  or  through  electrodes  placed  on  the  skin 
surface. 

The  last-named  method  of  applying  currents  is  not  new.  It 
has  been  employed  by  several  persons,  but  with  serious  incon- 
venience, because,  by  rendering  the  skin  more  radiosensitive 
than  the  deep-seated  tumors,  they  have  produced  radiodermati- 
tis,  making  the  subsequent  application  of  the  current  impos- 
sible. 

A  natural  consequence  of  the  law  controlling  the  relation  of 
temperature  to  radiosensitiveness  led  de  Keating-Hart  to  obvi- 
ate the  difficulty  just  mentioned  by  cooling  the  organs  which  he 
would  protect.  This  is  accomplished  by  several  methods,  two 
of  which  may  be  mentioned. 

First,  the  surface  to  be  protected  by  cooling  is  covered  with 
cracked  ice  wrapped  in  cotton. 

Second,  a  special  apparatus  may  be  employed  which  cools 
by  blowing  the  dampened  surface  with  a  bellows. 

Whenever  possible,  X-rays  should  be  applied  during  the  heat- 
ing of  the  cancer,  especially  when  the  neoplasm  is  small  and 
superficial.  If  the  mass  is  deeply  situated,  as  in  uterine  can- 
cer, it  may  retain  its  warmth  long  enough  for  the  irradiation 
to  follow  immediately  after  the  warming  process. 

The  irradiation  must  be  subjected  to  the  usual  rules  of  radio- 
therapy. The  longer  and  more  frequent  the  exposures,  without 
destroying  the  surrounding  normal  tissues,  the  more  rapid  are 


320  THE   CANCER   PROBLEM 

the  local  results.  The  results  may  sometimes  be  too  rapid, 
which  fact  calls  for  great  care,  inasmuch  as  the  cytolysis  of 
the  tumor  may  be  the  cause  of  serious  autointoxication.  This 
is  particularly  true  of  epithelial  tumors. 

Conclusions. — From  a  study  of  the  data  cited,  and  from  his 
clinical  observations,  de  Keating-IIart  arrived  at  the  following 
conclusions  with  reference  to  thermoradiotherapy: 

(1)  That  the  X-rays  have  a  more  intense  action  upon 
warmed  than  upon  cold  cells. 

(2)  That  the  application  of  this  principle,  by  previously 
cooling  the  surface  of  the  normal  tissues  to  be  traversed  by  the 
X-rays,  produces  more  rapid  destruction  of  the  cancerous  tissue 
with  a  weaker  dose. 

(3)  That  this  treatment  is  applicable  to  the  majority  of 
cancers,  but  the  autointoxication  brought  about  by  the  cytolysis 
renders  it  advantageous  to  remove  as  much  as  possible  of  the 
cancer  and  to  fulgurate  the  field  of  operation  in  operable 
cases. 

(4)  That  in  inoperable  cases,  and  with  patients  who  refuse 
all  operative  interference,  thermoradiotherapy  alone  may  be 
employed,  care  being  taken  to  prevent  too  rapid  cytolysis  and 
consequent  autointoxication. 

(5)  That  cases  in  which  the  cancer  has  been  completely  re- 
moved and  fulgurated  show  the  same  sensitiveness  to  X-rays 
as  do  warmed  cancers. 

DIATHERMY,    OR    TRANSTHERMY    (Nagelschmidt) 

In  1907,  Nagelschmidt,  in  Berlin,  and  von  Brendt,  Preyss, 
and  Zeynek,  in  Vienna,  experimented  independently  with  the 
thermopenetrative  power  of  the  high-frequency  current.  Since 
that  time  this  method  has  been  employed  by  surgeons  in  differ- 
ent centers,  generally  under  the  name  diathermy,  applied  by 
ISTagelschmidt.  The  apparatus  employed  permits  the  elevation 
of  the  temperature  of  the  deep  tissues  to  any  required  extent, 
the  tumor  being  destroyed  by  the  coagulation  of  the  tissues. 
This  is  merely  a  thermic  means  of  destruction,  having  no  effect 
upon  the  trophic  centers,  or  upon  the  soil  upon  which  the  can- 
cer flourishes.  It  is  claimed  by  its  advocates  that  the  tumor 
may  be  heated  to  the  depth  of  10  to  15  cm.,  and  that  the  heat 
is  dosable  and  localizable.  Those  who  do  not  advocate  the 
method  hold  that  the  cancer  cells  in  the  vicinity  not  reached 
are  not  destroyed,  and  that  those  which  are  reached,  but  not 
destroyed,  are  stimulated  to  heightened  vitality. 


PHYSIOTHERAPY  321 

Nagelschmidt  -^  gave  a  practical  demonstration  of  his  method 
at  the  Dresden  Congress  in  1907.  The  essential  high-fre- 
quency apparatus  which  he  employs  "consists  of  an  undulatory 
electrical  circuit,  including  a  spark-gap,  a  capacity  and  a  self- 
induction,  in  which  electrical  waves  are  produced  by  oscillatory 
discharges  across  the  spark-gap.  This  is  the  principle  of  all 
high-frequency  apparatus.  The  only  differences  are  found  in 
the  construction  of  the  spark-gap,  the  ratio  of  capacity  to  self- 
induction,  with  the  addition  of  symmetric  or  asymmetric  con- 
densers and  oscillatory  circuits,  induction  or  magnetic  coupling, 
or  secondary  coils.  It  matters  not  whether  we  use  as  a  spark- 
gap  two  metallic  spheres,  two  metal  plates,  or  the  Poulsen  arc, 
— or  whether  we  use  a  constant  or  an  interrupted  current.  The 
essential  with  all  the  above  apparatus  is  the  introduction  of  a 
more  or  less  high-tension  current,  which  is  transformed  into 
electrical  undulations  of  high-frequency."  The  length  of  the 
waves  may  vary  from  100  meters  to  several  kilometers.  The 
number  of  vibrations  may  be  from  100,000  to  many  millions 
per  second.  The  damping  of  the  vibrations  is  the  only  im- 
portant difference. 

ELECTROCOAGTriATION    (Doyen)  » 

Doyen,  after  experimenting  to  determine  the  thermal  death- 
point  of  cells,  concluded  that  cancer  cells  are  destroyed  by  a 
temperature  of  122-131°  F.  (50-55°  C).  Normal  cells  were 
found  to  be  resistant  up  to  140°  F.  (60°  C).  He  employed 
the  high-frequency  current  for  the  production  of  the  thermic 
death  of  cancer  cells,  devising  for  the  purpose  a  special  appara- 
tus. The  cell  destruction  is  the  result  of  tissue  coagulation^ 
just  as  is  the  case  with  diathermy.  At  the  ISTew  York  Skin  and 
Cancer  Hospital,  with  the  Doyen  apparatus  used  for  both  elec- 
trocoagulation (Doyen)  and  diathermy  (Nagelschmidt),  it  is 
possible  to  coagulate  tissues  to  a  depth  of  5  to  8  centimeters  in 
from  one  to  two  minutes.  The  apparatus  produces  a  current  of 
about  three  million  oscillations  per  second,  and  of  a  strength  of 
from  10  to  15  amperes.  The  active  electrode  is  placed  directly 
in  contact  with  the  tissue,  thereby  suppressing  all  sparks.  The 
indifferent  electrode  is  placed  in  contact  with  any  part  of  the 
body,  while  the  active  is  placed  in  direct  contact  with  the  lesion 

1  Nagelschmidt. — ' '  The  Thermic  Effects  Produced  by  High-Frequency 
Currents."  (Report  presented  to  the  Third  Congress  of  Physiotherapy  at 
Paris,  1910.)     Archives  of  the  Roentgen  Eay,  Vol.  15,   1910-11,  p.  58. 

Also:     "The  Method  of  Diathermy  in  Medicine,"  ibid.,  p.  132. 
"Lehrbuch  der  Diathermy,"  Berlin,  1913. 

2  See  General  Bibliography. 


322  THE   CANCER   PROBLEM 

to  be  treated.  The  current  is  allowed  to  pass  for  from  20  to  60 
seconds.  If  this  is  not  sufficient  to  coagulate  the  entire  tumor 
mass,  a  second  application  may  be  employed.  The  slough  sep- 
arates in  from  ten  to  fifteen  days. 

xVt  the  Fourth  Cong  res  de  Physiotherapie  de  Medecins  de 
Langue  Franqaise,  held  at  Paris,  April  9-11,  1912,  Doyen 
confirmed  the  report  of  the  successful  treatment  of  all  varieties 
of  cancer  which  are  readily  accessible,  by  means  of  his  method 
of  electrocoagulation,  without  the  use  of  the  knife.  He 
claimed  to  have  had  satisfactory  results  in  cancer  of  the  skin, 
lip,  tongue,  tonsils,  pharynx,  larynx,  neck  of  the  uterus,  and 
rectum.  He  considered  that  the  lapse  of  time  and  the  experi- 
ence of  others  with  his  method  vindicated  his  claims. 

BIPOLAR   VOLTAIZATION    (Doyen) 

When  the  electrode  of  the  Doyen  apparatus  is  held  away 
from  the  part  to  be  treated,  and  the  sparks  are  allowed  to  play 
upon  the  area,  a  superficial  carbonization  takes  place,  the  un- 
derlying tissues  being  coagulated  as  when  the  electrode  is 
placed  directly  in  contact  with  the  part,  although  not  to  the 
same  depth.  To  this  method  Doyen  applied  the  term  bipolar 
voltaization. 

OSCILLATORY    DESICCATION    (Clark) 

According  to  Clark,  heat  effects  range  in  degree  from  hypere- 
mia to  burning,  and  somewhere  between  these  two  extremes 
there  is  a  point,  the  effect  of  which  is  more  than  hyperemia 
and  less  than  burning,  which  may  be  called  the  desiccation 
point.  His  method  of  treating  malignant  neoplasms  consists 
in  the  production,  the  control,  and  the  maintenance  of  heat  suffi- 
cient to  cause  rapid  desiccation  of  the  part  to  be  treated,  steriliz- 
ing and  converting  it  into  an  inert  mass.  This  is  accomplished 
by  a  specialized,  true  oscillatory,  high-frequency  current,  con- 
centrated to  a  very  fine  metal  point,  and  delivered  in  sparks  of 
great  frequency  through  an  air  space  to  the  tissue.  He  employs 
a  static  machine  with  a  large  output  (3  to  6  milliamperes). 

Clark  ^  concludes  from  his  clinical  investigations  as  follows : 
"A  current  from  a  static  machine  of  large  output  with  prop- 
erly attuned  accessories,  when  applied  with  correct  technic  and 
care,  is  capable  of  producing  a  superficial  or  a  deep  destruction 
of  tissue  by  desiccation,  or  rapid  depletion  of  its  fluid  elements, 
which  breaks  up  and  disintegrates  the  cells. 

1  Clark,  William  L. — ' '  Oscillatory  Desiccation  in  the  Treatment  of  Acces- 
sible Malignant  Growths  and  Minor  Surgical  Conditions.  A  New  Electrical 
Effect,"  Jour,  of  Advanced  Therapeutics,  1911,  Vol.  29,  p.   169. 


PHYSIOTHERAPY  323 

"It  has  sterilizing,  styptic,  and  stimulating  properties. 

"This  specialized  current  has  no  particular  affinity  for  ab- 
normal tissue  over  the  normal,  but  it  is  a  simple  matter  to  keep 
the  destruction  well  within  bounds  on  account  of  refinement 
of  control. 

"It  is  operative  in  all  accessible  lesions  where  destruction  is 
desirable,  and  works  from  without  inward. 

"Living  tissue  is  destroyed  by  this  means  almost  as  readily 
as  dead  tissue  (raw  meat). 

"The  rapidity  of  action  appears  to  be  directly  proportionate 
to  the  density  of  the  tissue." 

This  method  is  often  referred  to  as  fulguration.  Fulgura- 
tion,  "as  practiced  at  home  and  abroad  for  several  years,"  ac- 
cording to  Clark,  "is  not  desiccation,  the  thermic  degree  being 
too  high,  and  the  impact  against  the  tissue  too  severe."  He 
doubtless  refers  to  the  so-called  "destructive  fulguration." 

IONIC    SURGERY 
(Cataphoresis) 

With  the  purely  local  origin  of  cancer  as  the  basis  of  his 
theory,  G.  Betton-Massey  has  elaborated  a  method  of  treat- 
ment to  which  he  has  given  the  name  Ionic  Surgery.^ 

The  requisites  for  any  method  in  such  cases  are  that  it  "acts 
as  quickly  and  thoroughly  as  the  knife  in  a  favorable  case  for 
that  method,  and  yet  is  capable  of  application  through  the 
growth  itself,  from  within  outward,  enabling  us  to  reach  the 
actual  periphery  of  the  latter  by  a  combined  destructive  and 
occlusive  agency,  devitalizing  all  cells  in  situ  and  sterilizing 
the  outermost  edge  while,  at  the  same  instant,  sealing  the  ab- 
sorbents, thus  effectually  preventing  operative  reinfection." 

According  to  Massey,  and  others  who  have  followed  his  work, 
these  requirements  are  met  by  the  massive  diffusion  of  the  ions 
of  mercury  and  zinc  by  powerful  electric  currents,  as  devised 
and  developed  by  him. 

Furthermore,  that  the  diminishing  density  of  the  diffused 
ions  will  produce  a  zone  of  reaction  beyond  the  area  of  total  ne- 
crosis, thus  destroying  outlying  latent  cancer  cells,  and  only 
arousing  the  physiological  resistance  of  the  normal  tissues. 

The  method  of  Betton-Massey  consists  in  the  "utilization  of 
the  electrolytic  and  phoretic  powers  of  a  strong  electric  current 
for  dissolving  and  ionizing  zinc  points  or  needles  coated  with 
mercury  and  thrust  into  the  growth."     By  this  means,  and 

1  Betton-Massey,  G. — '  *  Ionic  Surgery  in  the  Treatment  of  Cancer, ' ' 
1910. 


324  THE   CANCER   PROBLEM 

with  tlie  patient  anesthetized,  it  is  claimed  that  a  snfficient 
quantity  of  mercury  and  zinc  may  be  interstitially  diffused 
throughout  a  tumor  in  a  few  minutes  to  kill  all  malignant  cells 
and  their  accompanying  germs,  should  such  be  present. 

By  prolonging  the  process  sufficiently  the  microbicidal  sub- 
stances will  be  driven  farther  than  the  apparent  boundaries  of 
the  growth  in  strength  sutKcient  to  kill  outlying  colonies  and 
lines  of  dissemination  in  the  immediate  neighborhood,  without 
serious  injury  to  the  contiguous  healthy  tissues. 

The  physiological  basis  of  this  method  of  the  ionic  steriliza- 
tion of  diseased  foci  is  the  fact  that  living  tissues,  particularly 
such  highly  cellular  and  vascular  tissues  as  malignant  growths, 
consist  of  various  salts  in  organic  combination  held  in  solution 
in  water. 

In  a  period  of  time  varying  from  twenty  minutes  to  one  hour, 
according  to  the  size  and  situation  of  the  growth,  with  proper 
placement  of  the  electrode,  the  whole  of  the  apparent  limits 
of  the  diseased  tissues  will  be  included  in  the  area  of  necrosis. 
Both  sight  and  touch  determine  the  completeness  of  this  effect. 
A  change  of  color  to  grayish  white  is  noted  by  the  eye,  and  a 
distinct  softening  of  the  brawny  induration  is  perceptible  to 
the  touch. 

SUMMARY 

Phototherapy. — The  use  of  light  in  the  treatment  of  cancer 
is  mainly  restricted  to  the  alleviation  of  pain ;  beyond  this  it  is 
of  no  real  benefit,  and  has  been  generally  abandoned  for  other 
methods. 

X-Rays. — Without  question  the  X-ray  has  a  marked  analgesic 
effect  which  lasts  several  days  after  an  application,  often  there- 
by deceiving  the  patient  into  the  belief  that  there  is  an  im- 
provement in  his  condition,  and  very  materially  aiding  in 
inspiring  an  element  of  hope.  Certain  superficial  growths, 
such  as  small  squamous-celled  carcinoma,  can  be  made  to  dis- 
appear by  the  correct  application  of  the  ray,  and  in  many  cases 
the  progress  of  a  malignant  growth  can  be  stayed  for  a  time. 
The  permeation  nodules  recurring  after  operation  will  often 
disappear  under  irradiation,  and  a  large  adenomatous  arm  may 
diminish  in  size.  In  deep-seated  cancer,  however,  the  beneficial 
effect,  when  obtained  at  all,  is  temporary  and  palliative.  On 
the  other  hand,  growth  may  be  accelerated  and  metastasis  has- 
tened. A  new  X-ray  tube  has  been  introduced  called  the 
Coolidge  tube,  which  is  constructed  on  a  new  principle,  and 
which  is  capable,  it  is  claimed,  of  producing  very  penetrating 
rays,  simulating  the  gamma  rays  of  radium.     This  tube  gives 


PHYSIOTHERAPY  325 

promise  of  increasing  the  field  of  usefulness  of  the  X-ray,  but 
it  has  not  been  employed  a  sufficient  length  of  time  to  establish 
its  scope  and  limitations. 

Radium,  Mesothorium,  and  Other  Radio-active  Substances. — 
Eadium  and  other  radio-active  substances  have  probably  other 
than  caustic  or  purely  destructive  effects.  Radium  may  cer- 
tainly be  described  as  the  most  efficacious  of  all  caustics,  but  in 
addition  it  has  an  effect  on  all  growing  tissues.  This  fact  is 
the  main  justification  for  its  use  in  cancer.  Its  field  of 
usefulness  is  in  the  treatment  of  superficial  lesions,  such  as 
rodent  ulcer,  and  certain  benign  conditions,  keloids,  angio- 
mata,  nsevi,  verrucse,  etc.,  which  can  be  cured.  There  is  no 
evidence  to  show  that  radium  has  any  but  a  palliative  effect 
upon  deep-seated  cancer.  It  has  been  claimed  by  some  that 
radium  may  in  some  instances  convert  an  inoperable  growth 
into  an  operable  one.  This  is  debatable.  It  is  too  early,  how- 
ever, to  give  a  positive  opinion  as  to  the  true  value  of  radio- 
active substances  in  the  treatment  of  cancer.  The  materials 
are  being  thoroughly  tested  in  the  various  centers  and  by  many 
individuals,  the  author  among  others.  Whatever  place  of  use- 
fulness they  may  have  can  be  determined  only  after  a  sufficient 
time  has  elapsed. 

The  combination  of  radiotherapy  with  surgery  is  very  prom- 
ising. Czerny  believes  that  mesothorium  is  of  more  value  in 
treatment  than  radium,  but  this  has  yet  to  be  demonstrated. 
The  words  of  Charles  Ryall,  F.R.C.S.,  Chairman  of  the  Medical 
Committee  of  the  London  Cancer  Hospital,  are  very  appro- 
priate at  the  present  time:  "It  would  be  well  if  those  who 
are  experimenting  with  radium  would  be  silent  for  the  next 
couple  of  years  until  they  know  where  they  are,  and  can  make 
some  definite  announcement.  Radium  has  not  come  to  sup- 
plant surgery  in  the  treatment  of  cancer,  but  to  aid  it  in  fighting 
the  disease." 

The  investigator,  seeking  to  learn  the  value  of  radio-active 
substances  in  the  treatment  of  malignant  disease,  after  reading 
the  many  opinions  in  this  chapter  will  readily  conclude  that, 
despite  the  extravagant  claims  made  by  some,  the  whole  matter 
is  in  an  experimental  stage.  We  would  emphasize  that  it 
is  too  early  to  determine  the  true  value  of  these  agents  in  the 
treatment  of  cancer.  A  better  understanding  of  physics,  and 
an  improved  technic,  may  lead  to  a  fulfilment  of  some  of  the 
hopes  with  reference  to  these  substances. 

Fulg^ration,  Electrocoagulation  and  Thermoradiotherapy. — 
During  the  past  three  years  the  author,  with  the  assistance  of 
Dr.  Worthington  Seton  Russell,  has  employed  these  methods 


326  THE   CANCER   PROBLEM 

ill  over  four  hundred  eases  of  all  forms  of  malignant  growths 
with  some  encouraging  results  which  warrant  a  continued  test. 
Fulguration,  as  has  been  stated  in  the  text,  is  a  post-operative 
procedure,  and  seems  to  oU'er  in  many  instances  more  hope 
than  surgery  alone,  although  the  radical  removal  employed 
may  be  the  real  beneficial  factor  and  not  the  high-frequency 
electricity.  It  will  take  time  and  a  careful  comparison  of  re- 
sults to  settle  the  question  of  fulguration's  place  of  usefulness. 
Our  results  in  conjunction  with  thorough  excision  of  all  micro- 
scopic cancer  are  gratifying  enough  to  warrant  a  continued 
trial.  ElectrocoagTilation  may  be  used  with  or  without  a  surgi- 
cal procedure,  and  is  of  decided  benefit  in  cleaning  up  ulcer- 
ating masses.  Thermoradiotherapy  seems  of  benefit  in  inoper- 
able cases.  A  detailed  report  of  our  work  will  be  forthcoming 
in  a  short  time. 

Other  Methods. — The  various  other  methods  given  in  this 
chapter  have  their  advocates,  but  have  not  been  accepted. 


CHAPTEK    III 
BIOTHERAPy 

CLASSIFICATION    OF   AGENTS 

For  a  decade  or  more  attention  has  been  very  largely  di- 
rected toward  the  treatment  of  cancer  along  biological  or  bio- 
chemical lines.  In  the  majority  of  instances  the  method  of 
treatment  is  founded  upon  a  theory  of  the  etiology  of  the  dis- 
ease. The  theory  failing  of  proof,  the  method  has  generally 
met  with  skepticism  and  discouragement,  only  the  adherents 
of  the  given  theory  continuing  the  systematic  employment  of 
the  correlated  method  of  treatment. 

The  production  of  sera  neutralizing  the  products  of  bacteria, 
and  actually  injurious  to  the  bacteria  themselves,  has  played 
an  important  part  in  therapeutic  endeavors  to  deal  with  cancer. 

The  discovery  that  sera  could  be  prepared  which  would  dis- 
solve red  blood  corpuscles  in  the  test  tube,  and  subsequently 
that  kidney,  liver,  and  other  epithelial  cells  could  be  dissolved 
by  injecting  them  into  other  animals,  gave  rise  to  the  hope  that, 
similarly,  sera  might  be  prepared  having  actions  limited  to 
special  tissues.  Naturally  the  possibilities  of  a  biological 
therapy  for  cancer  sprang  into  renewed  prominence,  in  which 
it  was  sought  to  utilize  the  reactions  of  the  living  body,  not 
against  supposed  organismal  causes  of  cancer,  but  against  ac- 
tual cells.  Therefore  these  measures  fall  into  many  groups, 
according  as  they  are  based  upon  bacteriology  or  upon  the 
cytolysins  or  cytotoxins,  but  the  confused  use  of  the  terminol- 
ogy of  bacteriology  in  describing  the  cellular  (cytolytic)  en- 
deavors, makes  sharp  separation  impossible. 

The  various  biological  measures,  however,  may  be  consid- 
ered under  the  general  heads  of: 

(1)  Serotherapy. 

(2)  Vaccine  therapy. 
(  3 )      Opotherapy. 

The  confusion  of  phraseology  with  reference  also  to  the  vari- 
ous biological  measures  used  in  the  treatment  of  cancer,  renders 

327 


328  THE   CANCER   PROBLEM 

it  practically  impossible  to  formulate  a  definite  classification. 
The  following  terms  are  employed  by  the  majority  of  writers 
with  a  degree  of  careless  overlapping  which  too  often  charac- 
terizes medical  literature : 

(1)  Bacterial  toxins. 

(2)  Antitoxic  sera. 

(3)  Antitoxins. 

(4)  ^'Toxins"  or  "Fluids." 
(  5  )      Vaccines. 

(G)     Residues,  Extracts,  and  Emulsions. 

(7)  Serous  exudates  (Sera), 

(8)  Opotherapeutic  measures. 

An  excellent  illustration  of  this  confusion  of  terms  is  fur- 
nished by  the  Coca-Gilman  "Vaccine  Emulsion,"  which  is 
referred  to  by  very  nearly  all  the  terms  employed  in  the  fore- 
going classification.  Another  illustration  is  the  "Cytolytic 
Serum"  of  von  Leyden  and  Blumenthal. 

In  the  above  list  it  is  impossible  to  determine  whether  the 
authors  would  or  would  not  agree  that,  by  "bacterial  toxins," 
"toxins,"  or  "fluids,"  the  same  group  of  agents  is  meant.  The 
same  applies  to  antitoxic  sera  or  antitoxins.  Vaccines,  resi- 
dues, extracts,  and  emulsions  may  likewise,  at  the  hands  of  one 
author,  signify  identical  procedures,  and  at  the  hands  of  an- 
other, something  different,  owing  to  the  one  conceiving  the 
existence  of  an  intracellular  cancer  parasite  and  another  en- 
tertaining only  cellular  conceptions. 


DEFINITION    OF   TERMS 

In  view  of  this  confusion  it  may  not  be  amiss,  particularly 
for  the  convenience  of  readers  who  have  made  no  special  study 
of  the  subject,  to  define  briefly  the  various  terms  under  which 
the  biological  treatment  of  cancer  has  been  considered.  It 
should  be  borne  in  mind  that  many  of  the  procedures  are  really 
only  haphazard  experiments  in  treatment. 

Serotherapy  is  the  treatment  of  infective  diseases  by  means 
of  sera  of  immunized  animals.  It  may  be  preventive  or  cura- 
tive, or  both.  The  animal  furnishing  the  serum  has  produced 
its  own  immunity ;  in  other  words,  it  possesses  active  immunity 
which  can  be  transferred  to  other  animals  by  injecting  its  im- 
mune serum.  The  animal  which  receives  such  a  serum  ac- 
quires a  passive  immunity.  It  is  readily  understood,  from 
w^hat  is  known  as  well  as  from  the  lack  of  knowledge  concern- 


BIOTHERAPY  329 

ing  cancer,  how  diflScult  it  is  to  apply  the  ordinary  bacteriologi- 
cal definitions  to  the  treatment  of  this  disease.  In  many  cases 
they  are  carelessly  so  applied  as  the  result  of  false  analogies 
with  the  infective  diseases. 

Antitoxin;  Antitoxic  Serum;  Bacterial  Toxins. — An  antitoxin 
is  a  substance  in  the  serum  which  binds  and  neutralizes  toxins. 
According  to  the  side-chain  theory  of  Ehrlich,  it  consists  of 
receptors,  which  have  been  produced  in  excess,  and  which  have 
been  thrown  off  into  the  body  fluids.  In  other  words,  an  anti- 
toxin is  developed  in  the  body  as  a  result  of  the  introduction  of 
a  poison,  and  acting  as  a  neutralizer  of  that  poison.  Antitoxin 
has  not  been  separated  pure,  that  is,  freed  from  all  albuminous 
substances  in  the  blood  serum. 

An  antitoxic  serum  is  one  which  contains  the  antitoxin  of 
the  pathogenic  micro-organism,  against  infection  by  which  it 
is  protective  or  curative.  A  specific  serum  contains  a  large 
number  of  amboceptors  (according  to  the  side-chain  theory) 
which  have  a  special  affinity  for  a  given  bacterium  or  the  red' 
cells  of  one  animal  in  particular,  and  which  serve  to  bind  the 
complements  (the  active  elements  in  lysis)  in  either  specific  or 
normal  serum  to  these  cellular  elements,  and  so  to  effect  their 
destruction. 

Examples  of  antitoxins,  antitoxic  sera,  and  bacterial  toxins 
which  have  been  employed  in  the  treatment  of  cancer  are : 

( 1 )  Blastomycetic  antitoxic  serum  of  Sanf elice,  based  upon 
the  theory  that  cancer  is  due  to  blastomycetes. 

(2)  Wlaejf's  Serum,  made  from  cultures  of  blastomycetes 
from  cancerous  growths,  inoculated  into  pigeons. 

(3)  Serum  of  Emmerich  and  ScJioll,  made  by  inoculating 
sheep  with  Streptococcus  erysipelatosus. 

(4)  Doyens  Serum,  from  Micrococcus  neoformans  (see 
Section  IX,  p.  256,  "The  Investigation  of  'Cancer  Cures'  "). 

(5)  Schmidt's  Serum,  from  Mucor  mucedo  (Cancroidin, 
Antimeristem).  (See  Section  IX,  p.  252,  The  Investigation  of 
^'Cancer  Cures.") 

(6)  Wyeth's  Toxins  of  Streptococcus. 

(7)  Coley's  Fluid — Mixed  toxins  of  Streptococcus  erysi- 
pelatosus and  Bacillus  prodigiosus. 

Vaccine;  Vaccination. — A  vaccine,  as  ordinarily  understood, 
is  the  modified  and  attenuated  virus  of  any  disease,  incapable 
of  producing  a  severe  infection,  but  affording  protection,  when 
inoculated,  against  the  action  of  the  unmodified  virus.  In  the 
case  of  cancer  the  term  is  frequently  used  to  mean  an  inocula- 
tion of  disintegrated  cancer  tissue  or  even  of  normal  tissue. 


330  THE  CANCER  PROBLEM 

According  to  Coca,^  "In  relatively  recent  times  the  use  of 
the  term  'vaccination'  has  been  extended  to  apply  to  the  injec- 
tion of  killed  cultures  of  pathogenic  bacteria  for  the  purpose  of 
artificially  inducing  an  active  immunity  against  the  living  or- 
ganisms. This  procedure  has  usually  been  resorted  to  as  a 
therapeutic  measure  during  a  subacute  or  chronic  infection  by 
the  respective  micro-organisms,  sometimes,  however,  during  an 
acute  infection  or  as  a  prophylactic  measure,  such  as  in  typhoid, 
cholera,  and  bubonic  plague." 

"If  we  inquire,"  he  continues,  "whether  there  are,  in  the 
literature  dealing  with  the  clinical  and  experimental  study  of 
malignant  tumors,  and  with  the  study  of  tissue-cell  immunity, 
any  facts  which  might  justify  the  application  of  the  vaccination 
therapy  to  the  treatment  of  malignant  disease  in  human  beings, 
we  find  that  such  facts  do  exist  in  abundance."  By  referring 
to  Section  VI,  p.  161,  under  immunity  reactions,  it  will  be  seen 
that  the  greatest  experimental  authors  absolutely  deny  that 
there  is  any  justification  for  Coca's  statements  regarding  vac- 
cination as  he  describes  it. 

Illustrations  of  vaccines  used  in  the  treatment  of  cancer 
may  be  found  in : 

(1)  Micrococcus  Neoformans  Vaccine  (Doyen),  used  in 
connection  with  the  serum  made  from  the  same  organism. 

(2)  Bacterial  Vaccine  (Jacob  and  Geets),  made  from 
Micrococcus  neoformans  cultures  of  the  same  age,  sterilized, 
washed,  and  standardized  according  to  the  opsonic  theory. 

Residues;  Extracts;  Emulsions. — These  are  preparations  of 
cancerous  material  or  of  normal  tissue,  to  be  injected  hypo- 
dermatically.  The  different  residues  or  extracts  are  referred  to 
as  sera  or  vaccines.    Conspicuous  examples  of  this  class  are : 

(1)  Coca-Gilman  Extract,  or  Emulsion. 

(2)  Vaughan  Residue. 

(3)  Fichera  Emulsion. 

(4)  Autolyzed  Cancer  or  Normal  Tissue.  (Pinkuss  and 
Kloninger. ) 

Serous  Exudates  and  Body  Fluids  (Sera). — Under  this  head 
come  the  various  body  fluids,  normal  and  pathologic,  which 
have  been  employed  in  the  treatment  of  cancer.  The  following 
are  examples: 

(1)  Hodenpyl's  Ascitic  Fluid  from  a  cancer  subject. 

(2)  Normal  Blood  Serum  (human). 

(3)  Blood  Serum  (horse)   (Strauss). 

1  Coca,  Arthur  F. — ' '  Vaccination  in  Human  Cancer  in  the  Light  of  the 
Experimental  Data  upon  Normal  Tissue  and  Tumor  Immunity,"  Zeitschr. 
fur  Immunitdtsforsch.  u.  Exp.  Therapie,  1912,  Vol.  13,  p.  524. 


BIOTHERAPY  331 

(4)  Blood  Serum  (donkey)  (Loeffler). 

(5)  Hydrocele  Fluid. 

(6)  Spermatocele  Fluid. 

(7)  Ascitic  Fluid  from  the  subject  of  alcoholic  cirrhosis. 

(8)  Ascitic  Fluid  from  the  subject  of  cardiac  insufficiency. 

(9)  Pleuritic  transudate  resulting  from  broken  compen- 
sation. 

Opotherapeutic  Measures  (organotherapy)  consists,  as  the 
name  implies,  of  preparations  of  certain  organs  or  parts  of 
animal  or  human  bodies.  Examples  of  agents  of  this  class 
are: 

(1)  "Antituman"  (Oestreich) — Embryological  cartilage 
and  arteries,  from  which  is  extracted  chondroitin-sulphate  of 
sodium,  supposedly  an  immunizing  substance. 

(2)  Thymus  Gland  Extract  (Gwyer). 

(3)  Extract  of  Sheeps'  Thyroids  (Am  Ende). 

(4)  Pancreatic  Enzymes — Trypsin  and  Amylopsin — 
(Beard). 

Among  the  various  biological  measures  mentioned  in  the 
foregoing  pages,  the  following  are  discussed  in  Section  IX: 
"The  Investigation  of  'Cancer  Cures'  " ;  Pancreatic  Enzymes 
(trypsin  and  amylopsin),  p.  242;  "Cancroidin"  or  "Antimeris- 
tem"  (Schmidt),  p.  252;  Micrococcus  neoformans  Serum  and 
"Vaccine  (Doyen),  p.  256. 

It  is  manifestly  impossible,  in  a  volume  of  this  scope,  to 
discuss  the  complete  list  of  biological  products  which  have  been 
proposed  in  the  treatment  of  malignant  diseases.  Nor  would 
such  a  discussion  be  profitable,  in  view  of  the  fact  that  many 
of  the  agents  have  been  discarded,  with  practically  a  consensus 
of  opinion  against  their  efficacy;  others  continue  to  receive  a 
certain  amount  of  attention,  largely  because  no  definite  test  of 
their  value  has  been  made  upon  a  convincing  basis ;  while  still 
others  are  being  given  careful  consideration  by  a  sufficient 
number  of  skilled  clinicians  to  warrant  the  hope  that  a  de- 
cision, pro  or  con,  will  be  soon  forthcoming. 

The  following  agents  are  considered  under  the  classification : 

( 1 )  Serotherapy. 

(2)  Vaccine  therapy. 
( 3  )      Opotherapy. 

For  the  benefit  of  those  who  may  desire  to  study  the  subject 
more  fully  a  fairly  comprehensive  bibliography  is  given. 


332  THE   CANCER   PROBLEM 


A.     BASED    ON    BACTERIOLOOT 

SERA 
(Bacterial  Toxins) 

Wlaeff's  Serum  (Blastomycetes). — In  1900  Wlaeff  *  claimed 
to  have  obtained  from  malignant  tumors  certain  parasitic  cells 
(blastomycetes),  which  had  the  power,  when  inoculated  into 
the  peritoneum  of  guinea-pigs,  of  producing  abdominal  cancer 
in  these  animals.  His  attempts  at  immunizing  different  ani- 
mals proved  successful  only  in  pigeons,  fowls,  and  geese, 
from  which  he  obtained  an  active  serum.  He  held  that  this 
serum,  administered  to  rats  previously  inoculated  with  blasto- 
mycetes, prevented  the  development  of  cancer. 

In  his  experiments  upon  human  beings  Wlaeff  used  a  serum 
obtained  from  geese,  5  to  10  c.  c.  being  given  with  each  injec- 
tion. In  his  own  experience,  when  given  early,  before  ulcera- 
tion and  glandular  enlargement  had  occurred,  the  serum  ex- 
erted a  curative  influence ;  when  metastasis  was  present  the 
serum  improved  the  patient's  general  condition  and  prolonged 
life,  but  did  not  effect  a  cure. 

Lucas-Champonniere,^  Berger,^  and  others  have  employed  the 
serum,  with  no  cures.  In  some  cases,  however,  improvement 
was  noted. 

The  injection  caused  considerable  local  and  general  reaction, 
but  nothing  more  serious. 

The  method,  so  far  as  I  am  aware,  has  been  abandoned. 

The  same  may  be  said  of  the  Blastomycetic  Antitoxic  Serum 
of  Sanfelice.'* 

According  to  Ewing,^  these  agents,  like  the  serum  of  Em- 
merich and  Scholl  ^  {Streptococcus  erysipelatosus) ,  Doyen's 
Serum  {Micrococcus  neoformans),  and  Schmidt's  Serum  {Mu- 
cor  mucedo),  may  cause  partial  retrogression  of  a  tumor,  after 

1  Wlaeff,  Gr. — ' '  Serum  anticellulaire. ' '  Compt.  rend.  Soc.  de  Biol.,  Paris, 
1900,  iii,  611-613. 

2  Lucas-Champonniere. — Discussion  of  Wlaeff 's  Serum,  Bull,  et  Mem. 
Soc.  de  Chir.  de  Paris,  1901,  xxii,  p.  174. 

3  Berger,  Paul. — Discussion  of  Wlaeff 's  Serum,  Bull,  et  Mem.  Soc.  de 
Chir.  de  Paris,  1901,  xxvii,  p.  174. 

4  Sanf  elice,  Francesco. — * '  Tossine  ed  antitossine  dei  blastomiceti  pato- 
geni  in  rapporte  alia  etiologia  ed  alia  eura  dei  tumori  maligni. ' '  Chap.  IV, 
Annali  d'Igiene  experimentale,  1908,  p.  521. 

5  Ewing,  James. — '  *  The  Treatment  of  Cancer  on  Biological  Principles, ' ' 
N.  Y.  Med.  Jour.,  October  19,  1912. 

6  Emmerich,  R.,  and  SchoU,  H. — ' '  Klinische  Erf  ahriingen  iiber  die  Heil- 
ung  des  Krebses  durch  Krebsserum  (Erysipelserum),"  Deutsch.  med. 
Woch.,  1905,  XXI,  265-268. 


BIOTHERAPY  333 

which  they  are  usually  ineffective.  "There  is  little  doubt,"  he 
says,  "that  complete  disappearance  of  malignant  tumors  has 
been  observed  in  a  small  proportion  of  cases  during  the  use  of 
these  agents."  He  agrees  with  Vidal  ^  concerning  the  pyroge- 
netic  nature  of  these  poisons,  i.  e.,  that  the  effect  on  the  tumor 
is  usually  proportional  to  the  fever. 

Wyeth's  Toxins  of  Streptococcus. — Wyeth  ^  reported  three 
cases  in  which  malignant  tumors  disappeared  after  septic  in- 
fection. 

Coley's  Fluid  (Mixed  Toxins  of  Streptococcus  erysipelato- 
sus  and  Bacillus  prodigiosv^) . — Of  the  various  bacterial  prod- 
ucts which  have  been  proposed  in  the  treatment  of  malignant 
neoplasms  the  one  which  has  attracted  most  attention  is  Coley's 
fluid.  Inasmuch  as  it  is  based  upon  the  curative  influence  of 
erysipelas,  it  may  be  interesting  to  review  briefly  the  evolution 
of  the  method. 

The  beneficial  effect  of  erysipelas  upon  concurrent  disease 
is  said  to  have  been  known  to  Hippocrates  (460-377  B.  C). 
Definite  observations  upon  the  subject  appeared  in  medical 
literature  in  the  seventeenth  century,  and  have  grown  grad- 
ually more  frequent  up  to  the  present  time.  Syphilis,  con- 
vulsions, epilepsy,  mental  diseases,  neuralgia,  typhus  fever, 
acute  rheumatism,  asthma,  lupus,  and  various  other  skin  dis- 
eases, including  malignant  new  growths,  were  thought  to  be 
mitigated  or  cured  in  certain  instances  by  a  concurrent  attack 
of  erysipelas. 

Cazenave  and  Schnedel,  in  1839,  endeavored  to  induce  ery- 
sipelas as  a  therapeutic  measure  in  the  treatment  of  skin  dis- 
eases. 

According  to  Eehleisen,^  the  discoverer  of  the  germ  (1883), 
and  naturally  a  close  observer  of  erysipelas  from  all  points  of 
view:  "It  is  undeniable  that  many  tumors  have  entirely 
disappeared  by  the  action  of  erysipelas.  Mistake  is  not  pos- 
sible as  to  this,  because  such  degeneration  of  new  formations 
does  not  otherwise  occur.  Many  swellings  of  the  skin,  epitheli- 
oma, keloid,  carcinoma  of  the  mamma,  and  lymphatic  gland 
enlargements  of  various  kinds,  have  been  partially  absorbed  as 
a  result  of  an  attack  of  erysipelas.     The  first  attempt  to  employ 

1  Vidal,  E. — Discussion  (La  resistance  des  cellules  concereuse,  etc.), 
Assoc.  Franc,  de  Chir.,  21  Congres  de  Chir.,  Paris,  1908,  p.  939.  Comptes 
rendus,  21  Congres  frangaise  de  chirurgie,  1908;  II  International  Cancer 
Conference,    1910,   p.    315. 

2  Wyeth,  John  A. — ' '  The  Value  of  Inoculations  with  Septic  or  Toxic 
Agents  in  the  Treatment  of  Malignant  Neoplasms,"  N.  Y.  Polyclinic,  July 
15,  1894;   also  Jour.  Am.  Med.  Assoc,  XXII,  1894,  p.  985. 

3  Fehleisen. — "On  Erysipelas"  (trans,  by  Leslie  Ogilve,  in  Micropara- 
sites  in   Disease),   edited  by  Watson  Cheyne,  p.   272. 


334  THE   CANCER   PROBLEM 

erysipelas  aa  a  curative  agent  was  made  by  Ricord  and  Depres, 
who  endeavored  to  reproduce  artificial  erysipelas  in  phagedenic 
chancres.  With  great  zeal  W.  Busch  *  followed  up  the  idea  of 
healing,  bv  means  of  erysipelas,  malignant  new  formations  of 
the  l;)Tnphatic  glands  which  were  unsuitable  for  operation.  He 
was  successful  in  infecting  a  patient  by  placing  her  in  a  bed 
in  which  patients  with  open  wounds  usually  became  attacked 
by  erysipelas.  The  desired  result  took  place,  and  the  swelling, 
which  was  an  extensive  lympho-sarcoma  of  the  neck,  disap- 
peared all  but  a  small  portion,  which,  however,  again  enlarged. 
The  result  was  thus  only  a  partial  one,  but  at  the  same  time  it 
encouraged  further  trials."  The  cases  of  Busch  and  Volk- 
mann  ^  convinced  Fehleisen  of  the  possibility  of  effecting  a 
permanent  cure. 

The  work  of  Fehleisen  was  followed  by  that  of  many  others, 
notably  Emmerich  and  Scholl,^  Bruns,*  Senn,'^  von  Jaksch,® 
and  ColeyJ 

The  manner  in  which  absorption  of  the  tumor  takes  place 
through  the  action  of  erysipelas  was  not  well  understood  by 
Fehleisen.  Supposedly  the  cells  of  the  tumor  appeared  to  have 
undergone  fatty  degeneration,  and  were  found  to  have  been 
transformed  into  a  "yellowish-white  emulsion,"  as  in  one  of  the 
cases  reported  by  him.  The  view  has  been  expressed  by  subse- 
quent observers  that  the  high  temperature  produced  during 
erysipelas  acts  upon  the  sarcoma  cell. 

Coley's  ®  attention  was  first  directed  to  the  curative  action  of 
accidental  erysipelas  in  inoperable  sarcoma  by  a  case  which  he 
observed  in  1891.  Among  90  cases  of  sarcoma  analyzed  by 
him  at  that  time,  which  had  been  operated  upon  at  the  New 
York  Hospital  during  the  preceding  fifteen  years,  was  one  of 

1  Busch,  W. — ' '  Einflusa  der  Erysipele  auf  organisirte  Neubildungen, ' ' 
Berl.  Jclin.  Woch.,  1866,  p.  245, 

2Volkmann,  E. — "Erysipelas,"  Billroth  and  Pitha. 

3  Emmerich,  R.,  and  SchoII,  H. — * '  Klinische  Erf  ahrungen  iiber  die  Heil- 
ung  des  Krebses  durch  Krebsserum  (Erysipelserum), "  Deut.  med.  Woch., 
1895,   XXI,   265-268;    Semaine   medicale,    1895.   220. 

♦  Brims,  P. — '  *  Zur  Kregsbehandlung  mit  Erysipelserum, ' '  Deut.  med. 
Woch.,    1895,   XXI,  313,  428;   Semaine   med.,   1895,   236. 

5  Senn,  N. — ' '  The  Treatment  of  Malignant  Tumors  by  the  Toxins  of  the 
Streptococcus  of  Erysipelas,"  Jour.  Am.  Med.  Assn.,  1895,  XXV,  129-131. 

6  Von  Jaksch,  R. — * '  Ueber  die  Behandlung  maligner  Tumoren  mit  dem 
Erysipelserum  von  Emmerich-Scholl, "  Mitth.  a.  d.  Grenzgeb.  d.  Med.  u. 
Chir.,  Jena,  1896,  I,  318-327. 

7  Coley.— See   General  Bibliography. 

8  Coley,  William  B. — ' '  The  Treatment  of  Inoperable  Sarcoma  by  Bac- 
terial Toxins  (The  Mixed  Toxins  of  the  Streptococcus  Erysipelatosus  and 
the  Bacillus  Prodigiosus), "  Proc.  of  the  Royal  Soc.  of  Medicine,  July, 
1909,  Vol.  3,  Part  III,  Surg.  Sect.,  pp.  1-48. 


BIOTHERAPY  335 

round-celled  sarcoma  of  the  neck,  four  times  recurrent.  At  the 
fifth  operation,  in  1884,  the  late  Dr.  William  T.  Bull  found 
the  tumor  to  involve  the  deep  structures  so  extensively  that 
removal  was  impossible  and  the  attempt  was  abandoned,  the 
case  being  regarded  as  absolutely  hopeless.  Shortly  after  the 
operation  a  severe  attack  of  erysipelas  developed  on  the  man's 
face  and  neck,  followed  two  weeks  later  by  a  second  attack.  A 
few  days  after  the  beginning  of  the  first  attack  the  tumor  began 
to  soften  and  decrease  rapidly  in  size.  When  the  patient  left 
the  hospital,  according  to  the  hospital  record,  the  tumor  had 
entirely  disappeared.  No  further  record  of  the  case  was  filed 
with  the  history,  but  Coley  succeeded  in  tracing  the  patient, 
and  found  him,  seven  years  after  the  operation  (1891),  well, 
and  with  no  evidence  of  local  or  general  recurrence. 

The  experiments  of  Fehleisen  were  unknown  to  Coley  at  that 
time,  but  he  was  so  strongly  impressed  by  this  case  that  he  de- 
termined to  try  inoculation  with  the  streptococcus  of  erysipelas 
in  the  first  suitable  case. 

This  opportunity  presented  itself  in  May,  1891,  when  he 
made  his  first  inoculation  in  a  case  of  recurrent  spindle-celled 
sarcoma  of  the  tonsil  and  neck.  The  history  of  this  case  is  de- 
tailed in  Coley's  paper  ^  on  the  subject. 

During  the  next  two  years  inoculations  were  employed  in  a 
number  of  chronic  and  incurable  cases  of  malignant  disease. 

These  experiments  with  living  cultures  convinced  Coley  that 
it  is  extremely  difficult  to  produce  erysipelas  at  will;  that  the 
risks  of  inoculation,  when  successful,  are  considerable,  and  that 
repeated  injections  of  the  streptococcus  of  erysipelas  exert  a 
distinct,  though  temporary,  inhibitor}'^  action  upon  the  grovs^h 
of  the  tumor.  He  concluded  from  his  observations  that  a  por- 
tion at  least  of  the  curative  action  of  the  erysipelas  lay  in  the 
toxic  products  of  the  disease,  which  might  be  utilized  without 
producing  an  actual  attack  of  the  disease. 

Accordingly,  in  1892,  Coley  began  his  experiments  with  the 
toxins  of  erysipelas.  He  found  the  constitutional  reaction  to 
be  very  similar  to  that  obtained  from  the  living  cultures.  Then, 
in  view  of  the  experiments  of  Rogers  with  the  Bacillus  pro- 
digiosus,  showing  that  this  organism,  when  grown  together  with 
the  Streptococcus  erysipelatosus,  intensified  the  virulence  of  the 
latter,  Coley  decided  to  combine  the  toxins  of  these  two  or- 
ganisms. 


1  Coley,  William  B. — "Contribution  to  the  Knowledge  of  Sarcoma," 
Annals  of  Surgery,  1891,  XIV,  p.  199;  also  Am.  Jour.  Med.  Sciences,  1893, 
Vol.  CV,  n.s.,  p.  487. 


336  THE   CANCER   PROBLEM 

Vaughan,^  of  the  University  of  Michigan,  bad  shown  that 
the  Bacillus  prodigiosus  toxins  are  among  the  most  powerful 
known,  a  fact  confirmed  by  Tracy's  -  experiments.  Further 
experiments  with  sarcoma  in  dogs  showed  that  this  disease 
would  disappear  under  injection  with  the  prodigiosus  toxins 
alone,  although  not  quite  so  rapidly  as  when  combined 
with  the  erysipelas  toxins.  Tracy  then  proceeded  to  grow 
the  two  organisms  separately  and  to  secure  a  standardiza- 
tion of  dosage  by  adding  a  certain  definite  quantity  of  the 
sterilized  prodigiosus  bouillon  to  each  ounce  of  the  strepto- 
coccus broth. 

In  March,  1895,  the  New  York  Surgical  Society  appointed 
a  committee,  consisting  of  Dr.  L.  A.  Stimson,  Dr.  A.  G.  Ger- 
ster,  and  Dr.  B.  T.  Curtis,  to  investigate  and  report  on  the  use 
of  erysipelas  toxins  in  the  treatment  of  malignant  disease.  At 
the  meeting  of  the  Society  on  March  25,  1896,  the  committee 
rendered  the  following  report :  ^ 

"Both  before  and  since  our  appointment  as  a  committee  we 
have  been  able  to  observe,  individually  and  together,  a  con- 
siderable number  of  cases  treated  by  this  means,  and  in  no 
case  have  we  found  any  amelioration  which  held  out  a  prospect 
of  ultimate  cure.  We  have,  on  the  contrary,  observed  in  some 
cases  that  the  rate  of  gTO\vth  of  the  disease  was  much  more 
rapid  during  the  treatment.  The  treatment  also  imposes  a 
very  severe  tax  upon  the  strength  of  the  patient,  and  appa- 
rently hastens  the  cachexia  in  most  cases. 

"We  believe  that  in  some  instances  of  apparent  cure  or 
marked  improvement  the  correctness  of  the  diagnosis  is  open 
to  doubt. 

"We  therefore  submit: 

"(1)  That  the  danger  to  the  patient  from  this  treatment 
is  great. 

"(2)  Moreover,  that  the  alleged  successes  are  so  few  and 
doubtful  in  character  that  the  most  that  can  be  fairly  claimed 
for  the  treatment  by  toxins  is  that  it  may  offer  a  very  slight 
chance  of  amelioration. 

"(3)  That  valuable  time  has  often  been  lost  in  operable 
cases  by  postponing  operation  for  the  sake  of  giving  the  method 
of  treatment  a  trial. 

"(4)  Finally,  and  most  important,  that  if  the  method  is  to 
be  resorted  to  at  all  it  should  be  confined  to  the  absolutely 
inoperable  cases." 

1  Vaughan,   Victor   C. — See   General   Bibliography. 

2  Tracy,  Martha. — See  General  Bibliography. 

3  "Results  of  Injections  of  Erysipelas  Toxins  upon  Malignant  Growths," 
Annals  of  Surgery,  1896,  XLIY,  53;  also.  Trans.  N.  ¥.  Surg.  Soc,  1896. 


BIOTHERAPY  337 

The  Surgical  Society  has  not  rescinded  the  decision  rendered 
by  this  committee. 

Moullin,^  after  an  experience  with  ten  cases,  mainly  sar- 
coma, reported  his  own  observations  and  reviewed  the  work  of 
others  up  to  that  time  (1898).  Careful  study  of  the  histories 
of  Moullin's  cases  at  the  London  Hospital  reveals  nothing  con- 
clusively in  favor  of  the  method. 

Bashford  "  has  tested  Coley's  fluid  in  mice,  with  no  results. 
His  conclusion  with  reference  to  it  is  as  follows :  ''The  fluid  is 
not  a  cure  for  cancer,  and  when  it  cures  I  should  take  it  as  evi- 
dence that  the  patient  was  being  treated  for  something  which 
was  not  malignant." 

Sir  Frederic  Eve  ^  reports  having  used  the  mixed  toxins  in 
five  cases  of  periosteal  sarcoma  at  the  London  Hospital,  with- 
out the  slightest  result  on  the  tumor.  His  experience  with 
reference  to  the  prevention  of  recurrence  by  Coley's  fluid  was 
most  disappointing.  "It  is  undeniable,"  he  says,  ''that  a  cer- 
tain number  of  sarcomata  disappear  under,  or  are  profoundly 
influenced  by,  the  toxins,  but  we  have  no  means  of  determining 
what  proportion  this  is  to  the  total  number  treated.  I  suspect 
it  is  only  a  small  proportion.  Although  I  may  be  forming  an 
opinion  on  insufficient  evidence,  yet  my  present  attitude  is  that 
I  would  not  recommend  Coley's  fluid  in  any  case  of  operable 
sarcoma,  nor  would  I  recommend  it  as  a  prophylactic  agent 
against  recurrence." 

My  own  experience  with  the  mixed  toxins  is  limited  to  about 
30  cases,  in  which  it  was  used  without  permanent  benefit.  In 
many  the  treatment  was  attended  by  severe  reactions  and  most 
distressing  symptoms.  I  have  not  felt  like  advising  the  method, 
particularly  in  view  of  the  fact  that  personal  communications 
from  5,000  representative  medical  men  throughout  the  civilized 
world,  in  response  to  questions  concerning  their  experience  with 
this  agent,  were,  with  few  exceptions,  unfavorable ;  and  that,  at 
the  New  York  Skin  and  Cancer  Hospital,  I  have  seen  some  hun- 
dreds of  advanced  cases  in  which  the  mixed  toxins  had  already 
been  employed  elsewhere  without  success. 

Despite  the  adverse  experience  of  others,  Coley  continues  to 
employ  his  method,  claiming  success,  as  will  be  seen  from  his 
numerous  publications.* 

In  addition  to  the  sera  above  mentioned,  a  number  of  others 

1  Moullin,  C,  Mansell. — ' '  The  Treatment  of  Sarcoma  and  Carcinoma  hj 
Injections  of   Mixed  Toxins,"   1898. 

2  Personal   communication. 

3  Eve,  Sir  Frederic. — "Eemarks  on  the  Treatment  of  Sarcoma  of  the 
Long  Bones,"  The  Lancet,  November  16,  1912,  p.  1355. 

4  Coley,  William  B. — See  General  Bibliography. 


338  THE   CANCER   PROBLEM 

which  come  within  the  category  of  parasitic  or  bacteriological 
toxins  have  been  proposed.  Inasmuch  as  none  have  proved 
successful,  space  need  not  be  sacrificed  for  their  consideration. 
The  literature  covering  the  majority  of  these  is  cited  in  the  bib- 
liography. 

B.   BASED  ON  CYTOLYSINS  OR  CYTOTOXINS 

VACCINES 

What  has  been  said  with  reference  to  the  majority  of  bac-' 
terial  products  which  are  classified  as  sera,  may  be  said  likewise 
of  those  which  come  within  the  category  of  vaccines.  The  vac- 
cines which  continue  to  engage  attention  are  those  which  are 
perhaps  more  commonly  mentioned  as  residues,  extracts,  emul- 
sions, or  autolyzed  tumor  or  normal  tissue.  They  will  be  con- 
sidered under  these  headings. 

RESIDUES;    EXTRACTS;    EMULSIONS 

Von  Leyden  and  Blumenthal  ^  were  the  first  to  attempt  the 
treatment  of  malignant  neoplasms  by  means  of  some  product 
extracted  from  the  tumor  itself. 

After  experimenting  successfully  with  the  treatment  of 
cancerous  dogs  by  means  of  the  serum  of  a  rabbit  that  had  been 
injected  with  cancer  from  a  dog,  they  found  it  possible  to  cure 
carcinoma  by  inoculating  the  animal  with  juice  expressed  from 
dog  carcinoma.  They  claimed,  likewise,  to  have  successfully 
treated  cancer  in  the  human  subject  by  the  injection  of  fluids 
expressed  from  human  cancer.  These  results,  according  to  von 
Leyden,-  were  substantiated  by  subsequent  investigations. 

According  to  Ewing,^  definite  cure  of  a  growing  cancer  by 
means  of  vaccination  "has  been  obtained  only  by  von  Dungern 
and  Coca  and  by  Gay."  Many  investigators  have  contributed 
to  the  literature  of  the  treatment  of  cancer  along  this  line,  and 
a  number  of  products  have  been  suggested.  The  most  promis- 
ing of  these  are  discussed  below. 

Coca-Gilman  *  Emulsion. — This  emulsion  is  prepared  from 

1  Von  Leyden  and  Blumenthal.— Pewt.  med.  Woch.,  1902,  XXVIII,  637. 

2  Von  Leyden.— Zett.  fiir  Krebsfsch.,  1907,  V,  164. 
3Ewing.— Op.  cit.,  N.  Y.  Med.  Jour.,  Oct.  19,  1912. 

*  Coca  and  Gilman. — Philippine  Jour,  of  Science,  IV,  B,  391,  1909;  also 
Zeit.  f.  Immunitatsfsch.,  XIII,  524,  543,  1909. 

See  also:     Von  Dungern-Coca. — Zeit.  f.  Immunitatsfsch.,  II,  391,   1909. 

Risley,  Edward  H. — ' '  The  Gilman-Coca  Vaccine  Emulsion  Treatment  of 
Cancer,"  Boston  Med.  and  Surg.  Jour.,  November  23,  1911,  p.  784. 

Gay,  Frederick  P.— Boston  Med.  and  Surg.  Jour.,  1909,  CLXI,  211;  Jour, 
of  Med.  Research,  XX,  I,  1909. 


BIOTHERAPY  S39 

living  cancer  cells  removed  by  operation.  It  contains  the 
protoplasmic  and  nuclear  elements  of  the  cells.  The  method 
of  preparation  is  a,8  follows  (Risley)  : 

"The  tumor  removed  at  operation  was  taken  under  sterile 
precautions  to  the  laboratory,  where  all  surrounding  connective 
and  other  extraneous  tissue  was  cut  carefully  away.  The  tumor 
material  was  then  cut  into  the  finest  possible  pieces  by  the 
scissors  and  ground  ten  times  in  a  vaccine  grinder;  after  the 
first  passage  through  the  grinder  an  equal  volume  of  sterile  nor- 
mal salt  solution  was  added  and  the  emulsion  ground  further. 
This  made  a  fairly  fine  emulsion  in  which  the  majority,  but  by 
no  means  all,  of  the  cancer  cells  were  disintegrated.  If  it  was 
certain  that  no  contamination  of  the  material  had  taken  place 
it  was  immediately  injected  into  the  abdominal  wall  of  the 
patient  from  whom  the  tumor  was  removed.  About  50  c.  cm. 
were  used.  The  remaining  portion  was  treated  with  1  c.  cm.  of 
5  per  cent,  phenol  and  set  aside  for  use  three  weeks  later.  The 
authors  soon  found  that  their  fear  of  transplants  and  toxic 
effects  were  unfounded,  as  neither  occurred,  even  with  the 
largest  doses  of  20  to  25  gm.  of  material.  Sterile  abscesses  at 
the  site  of  the  inoculation  were  common,  but  did  no  harm." 

It  is  impossible  to  review  all  the  results  of  the  clinical  ap- 
plication of  this  method.  A  fairly  representative  expression 
of  opinion  may  be  found  in  Eisley's  conclusions,  after  employ- 
ing the  emulsion  in  a  series  of  twenty  cases : 

"The  conclusions  arrived  at,  therefore,  from  this  series  are 
that  emulsions  or  extracts  of  cancer  injected  into  the  inoperable 
or  recently  operated  patient  with  recurrent  cancer  have  no 
effect  in  retarding  the  growth  or  preventing  recurrence,  but  in 
a  great  proportion  of  cases  produce  an  increased  activity  on  the 
part  of  the  cancer  cells,  so  that  tumors  grow  with  greater 
rapidity,  and  that  the  danger  of  sepsis  is  marked,  such  sepsis 
being  in  no  wise  beneficial  to  the  patient  or  his  cancer." 

It  is  interesting  to  note  that  a  study  of  seventy-nine  cases 
led  to  the  conclusion  *  that  the  injection  of  this  tumor-tissue 
emulsion  exerted  no  specific  influence  over  malignant  growths 
other  than  that  it  promptly  relieved  cachectic  symptoms.  / 

Vaughan,^  Residue. — This  is  made  from  material  from 
which,  by  special  process,  the  non-toxic  residue  is  extracted 
from  the  tumor. 

The  method  is  based  on  the  work  of  V.  C.  Vaughan,  who 

1  Coca,  Dorrance,  and  Lebredo. — Zeit.  f.  Immunitatsforschung,  etc.,  Jena, 
1912,  XIII,  543-585;  Mulford  Digest,  Philadelphia,  1912,  I,  96-103. 

-  Vaughan,  J.  W. — * '  The  Comparative  Value  of  Different  Methods  of 
Cancer  Treatment,"  N.  Y.  Med.  Jour.,  Oct.  15,  1910,  p.  759;  also  J.  A. 
M.  A.,  Nov.  16,  1912. 


340  THE   CANCER   PROBLEM 

demonstrated  that  a  cellular  proteid  mav  be  split  into  two 
definite  chemical  parts  by  heating  in  a  2  per  cent,  solution  of 
sodium  hydrate  in  absolute  alcohol.  When  the  residue  or  non- 
toxic radical  is  injected  into  an  animal,  that  animal  becomes  to 
a  certain  extent  immune  to  the  entire  proteid.  He  has  there- 
fore used  injections  of  cancer  residue  in  order  to  render  pa- 
tients more  or  less  immune  to  cancer.  His  work  has  been 
controlled  by  daily  blood  examinations  of  the  patients  under 
treatment,  with  interesting'  results.  "While  the  total  number  of 
white  blood  cells  is  not  altered  by  injections,  the  relative  pro- 
portion of  the  different  leukocytes  is  affected.  Following  an 
injection  of  cancer  residue  the  mononuclear  cells  increase 
within  48  hours  from  5  to  40  per  cent.,  while  in  the  polynu- 
clear  cells  a  corresponding  fall  is  seen.  He  draws  the  con- 
clusion that  a  specific  ferment  is  formed  probably  through  a 
reaction  with  the  mononuclear  white  blood  cells. 

Fichera  ^  Emulsion  of  Fetal  Products. — This  differs  from 
the  Coca-Gilman,  the  Vaughan,  and  other  extracts,  residues, 
and  emulsions  in  that  it  does  not  consist  of  cancerous  material 
at  all,  but  of  fetal  products  (autolysates). 

The  emulsion  is  prepared  from  human  embryos  and  fetuses 
of  from  tw^o  to  six  months  of  intra-uterine  life.  The  fragments 
are  placed  in  physiologic  salt  solution  in  the  proportion  of  one 
gram  to  twenty  centigrams.  Th^nnol  or  phenol,  in  suitable 
quantity,  is  added,  and  covered  by  a  layer  of  sterilized  oil  or 
toluol.  The  mixture  is  then  incubated  at  37  degrees  C.  for 
about  two  months.  After  carefully  testing  its  sterility  the 
homogeneous  autolysates  are  then  injected  in  doses  of  from  2 
to  3  c.  c.  twice  to  four  times  a  week,  according  to  the  specific 
gravity  of  the  autolysates,  the  size  of  the  tumor,  the  seat  of  the 
injections,  which  are  made  subcutaneously  or  directly  into  the 
tumor,  and  the  patient's  age,  condition,  and  degree  of  tolerance. 

Of  the  twenty-five  patients  treated  by  Fichera,  nine  showed 
no  improvement,  while  in  the  remaining  sixteen,  arrest  of  de- 
velopment, retrogression,  or  temporary  disappearance  of  the 
growth  occurred. 

1  Fichera,  G. —  (1)  "Treatment  of  Cancer  with  Autolysates  of  Human 
Fetuses,"  II  Policlinico,  July  3,  1910;  abstr.  in  the  Jour.  Am.  Med.  Ass., 
Aug.  6,  1910,  p.  545. 

(2)  "Gli  autolizzati  di  tessuti  nella  terapia  dei  tumori,"  II  Policlinico, 
February  12,  1911,  p.   197. 

(3)  "The  Action  of  Products  of  Homogeneous  Fetal  Autolysis  on  Ma- 
lignant Tumors  in  Man,"  Trans,  from  the  Italian  by  Alex.  R.  Coldstream, 
Lancet,  London,  Oct.  28,  1911,  p.   1194. 

(4)  "Tumori,"  Turin,  1911;  abstr.  in  Bull,  de  I'Institut  Pasteur,  1911, 
:T,  272. 


BIOTHERAPY  341 

Babcock  ^  reported  the  use  of  the  emulsion  in  twenty-one 
eases,  with  one  death,  apparently  the  result  of  anaphylaxis. 
He  concludes: 

"First. — Homogeneous  emulsions  or  autolysates  prepared 
from  human  fetuses  or  embryos  have,  in  our  experience, 
shown  no  distinct  value  in  the  treatment  of  malignant  disease 
in  man. 

"Second. — Spontaneous  or  inoculated  tumors  of  rats  and 
mice  are  susceptible  to  various  forms  of  treatment,  and  in  this 
way  differ  from  malignant  tumors  of  the  human  family.  Ex- 
perimental evidence  derived  from  tumors  in  the  lower  animals 
is,  in  many  instances,  misleading  and  valueless  as  applied  to 
human  practice.  The  favorable  effects  reported  from  novel  or 
unusual  methods  of  treatment  for  malignant  disease,  usually  re- 
sult from  the  enthusiasm  and  hope  attending  their  introduction." 


SEROUS  EXUDATES  AND  BODY  FLUIDS    (SERA) 

Ascitic  Fluid  (Hodenpyl).^ — Of  the  various  products  of  this 
class  the  one  which  attracted  most  attention  was  the  ascitic 
fluid  from  a  cancer  patient. 

Five  years  ago  Hodenpyl  became  interested  in  a  case  of  car- 
cinoma of  the  breast  in  a  woman  of  37  years  of  age.  "In  spite 
of  radical  operation,"  says  the  author,  "multiple  recurrences 
appeared  in  the  neck  and  in  the  primary  scar.  After  the  thor- 
ough removal  of  these,  secondary  growths  appeared  which  were 
morphologically  typical  of  rapidly  growing  carcinoma.  Still 
other  tumors  developed  in  the  neck  and  breast  which,  owing  to 
local  complications  and  the  debilitated  condition  of  the  patient, 
were  not  removed.  Later  large  tumors  developed  in  the  liver, 
which  nearly  filled  the  abdominal  cavity,  followed  by  the  re- 
currence of  excessive  chyliform  ascites.  The  prognosis  was 
unqualifiedly  bad  and  the  patient's  death  seemed  imminent." 

The  tumors  in  the  neck  and  breast,  however,  gradually 
dwindled  and  disappeared.  The  abdominal  tumors  gradually 
grew  smaller  and  became  imperceptible,  while  the  liver  dimin- 
ished in  size  and  the  surface  became  smoother. 

Finally,  about  four  years  after  the  first  operation,  the  liver 
had  become  approximately  normal  in  size  and  position.  When 
the  report  of  the  case  was  published  there  was  no  indication  of 

1  Babcock,  W.  Wayne. — ' '  Fetal  Products  in  the  Treatment  of  Carcinoma 
(Fichera's  Method),"  International  Clinics,  Vol.  II,  23rd  Series,  p.  81. 

2  Hodenpyl,  Eugene. — ' '  Treatment  of  Carcinoma  with  the  Body  Fhiids 
of  a  Eecovered  Case,"  Medical  Record,  Feb.  26,  1910.^ 

See  also :     Mackay,  Charles  Gordon. — Brit.  Med.  Jour.,  1907,  II,  138. 


342  THE   CANCER   PROBLEM 

the  original  disorder  other  than  the  scars,  the  decreasing  emaci- 
ation, and  the  extreme  chyliform  ascites,  requiring  frequent 
tappings. 

This  rare  case  of  seeming  recovery  from  extensive  carcinoma, 
with  residual  chyliform  ascites,  suggested:  (1)  the  theory  of 
the  formation  of  an  antibody  (often  discussed)  inimical  to 
the  progressive  growth  and  persistence  of  the  tumor  cells,  and 
(2)  the  alternative  hypothesis  that,  in  the  process  of  tumor- 
tissue  formation  in  the  abdomen,  some  physical  or  physiological 
disturbance  of  organic  or  internal  secretions  might  have  oc- 
curred, leading  to  the  accumulation  or  formation  of  substances 
antagonistic  to  tumor-cell  growth  or  existence. 

These  "theoretical  conceptions"  were  tested  with  ascitic  fluid 
from  this  patient,  first  upon  mice  which  had  developed  trans- 
plantation tumors,  and  then  upon  human  beings  suffering  from 
carcinoma  of  various  types.  The  fluid  was  injected  in  ''small 
quantities"  (amounts  not  stated)  near  or  directly  into  the  tu- 
mors, or  in  "large  quantities"  into  the  veins. 

The  general  effects  of  these  injections  in  man  have  been  the 
nearly  uniform  production  of  temporary  local  redness,  swelling, 
and  tenderness  about  the  tumors,  followed  by  quick  subsidence 
of  these  symptoms.  Softening  and  necrosis  of  the  tumor  tissue 
then  occur,  with  absorption  or  external  discharge  of  the  ne- 
crotic tissue,  and  subsequent  formation  of  more  or  less  con- 
nective tissue. 

Forty-seven  cases  were  reported  by  Hodenpyl,  the  greater 
number  being  distinctly  unfavorable,  many  of  them  hopeless 
and  inoperable.  In  all  cases  the  tumors  have  grown  smaller, 
in  some  they  have  disappeared  altogether.  In  no  instance  has 
any  tissue  other  than  the  tumor  shown  the  least  reaction  after 
the  injections,  nor  have  any  systemic  effects  been  manifest 
even  after  large  venous  infusions. 

The  purpose  of  the  report  from  which  quotation  has  been 
made,  was  to  call  attention  to  the  ''selective  necrotizing  effects 
upon  carcinoma  cells  of  the  ascitic  fluid  from  a  recovered  case 
of  carcinoma  wherever,  in  the  body  of  the  patient,  this  fluid  is 
introduced." 

The  records  of  cases  and  the  technic  of  the  administration 
of  the  fluid  were  promised  at  a  later  date.  Unfortunately  the 
untimely  death  of  Dr.  Hodenpyl  occurred  before  any  further 
report  was  made.    Others  have  continued  his  work. 

Some,  notably  Bevan,^  have  reported  the  unsuccessful  use  of 
the  fluid. 

1  Bevan. — See  General  Bibliography. 


BIOTHERAPY  343 

Ewing,*  in  a  personal  report  to  the  author,  said  that  all  cases 
treated  by  Hodenpyl  died  within  one  year.  The  physician's 
wife,  who  gave  the  serum,  and  who  was  supposed  to  have  been 
cured,  died  of  cancer  soon  after  the  death  of  Hodenpyl.  The 
animals  experimented  upon  with  the  serum  died. 

I  have  employed  ascitic  fluid  from  a  case  of  malignant  ova- 
rian papillomata,  according  to  the  suggestions  laid  down  by 
Hodenpyl,  with  six  patients,  but  without  success. 

Autolyzed  Cancer  or  Normal  Tissue. — This  has  been  em- 
ployed by  Pinkuss  and  Kloninger.^  They  describe  beneficial 
results,  but  the  evidence  is  unconvincing. 


OPOTHERAPEirriC    MEASURES 

Preparations  of  one  kind  or  another  have  been  made  from 
various  parts  or  organs  of  the  body — blood,  blood  vessels 
(arteries),  cartilage,  pancreas,  liver,  thyroid,  thymus,  and 
placenta.  None  of  these  have  been  convincing,  according  to 
published  reports,  and  they  may  be  passed  over  with  a  partial 
bibliographic  review.^ 

The  pancreatic  enzymes  were  thoroughly  tested  at  the  New 
York  Skin  and  Cancer  Hospital,  as  detailed  in  Section  IX, 
"The  Investigation  of  'Cancer  Cures,'  "  p.  242. 

STTMHABY 

The  results  described  in  the  employment  of  the  products  of 
bacteria  and  micro-organisms  in  general,  or  in  the  employment 

1  Ewing,    Personal   Communication. 

2  Pinkuss  and  Kloninger. — ' '  Zur  Vaccination-therapie  des  Krebses, ' ' 
Berl.  Uin.  Woch.,  Oct.  20,  1913,  p.  1941. 

3  Von  Leyden,  E.,  and  Bergell,  P. — ' '  Ueber  Pathogenese  und  iiber  den 
spezifischen  Abbau  der  Krebsgeschwiilste, "  Deut.  med.  Woch.,  1907,  Vol. 
33,  p.  913. 

Bergell,  P.,  and  Lewin,  C. — "Ueber  Pathogenese  und  iiber  den  spezi- 
fischen Abbau  der  Krebsgeschwiilste,"  Zeit.  f.  klin.  Med.,  1907,  Vol.  64, 
p.  185. 

Gwyer,  Frederick. — "Thymus  Gland  Treatment  of  Cancer,"  Annals  of 
Surg.,  July,  1907,  p.  86;  New  York  Med.  Jour.,  Feb.  19,  1910,  p.  373. 

Falk,  E. — "Injektion  von  Plazentablut  bei  Carcinom, "  Berl.  Tclin.  Woch., 
1908,  Vol.  45,  p.  1394. 

Woods,  E.  H. — "Carcinoma  of  the  Larynx.  Extirpation  of  primary  and 
secondary  growths;  glandular  recurrence;  treatment  with  thyroid  extract ;^ 
disappearance  of  growths,"  Brit.  Med.  Jour.,  July  1,  1911,  p.  5. 

Diesing. — "Die  Wirkung  von  Schildriisen  Extract  auf  Magendarm- 
krebse,"  Medis.  Klinik,  1911,  7,  p.  458. 

Carnot. — "  Opotherapie, "  Paris,  1911. 

Pinkuss,  A. — "Weitere  Erfahrungen  iiber  serologische  Diagnostik,  Ver- 
lauf  und  Behandlung  des  Karzinoms, "  Deut.  med.  Woch.,  1912,  p.  55. 


34.t  THE   CANCER   PROBLEM 

of  sera  containing  the  reaction  products  of  these  organisms  or 
their  toxins,  are  contradictory  in  the  extreme.  Curative  results 
have  occasionally  been  claimed,  but  they  are  counterbalanced 
by  what  is  probably  a  greater  number  of  negative  results,  since 
many  of  the  latter  are  not  likely  to  have  been  published.  The 
occasional  apparent  success  is  explained  in  some  cases  by  errors 
in  diagnosis.  It  may  be  surmised  that  when  benefit  has  oc- 
curred it  has  been  an  accidental  coincidence,  and,  perhaps  very 
rarely,  has  coincided  with  a  natural  tendency  for  a  tumor  to 
disappear. 

The  fact  that  bacteriological  results  have  been  forsaken  in 
the  newer  endeavor  to  find  something  derived  from  tumor  cells, 
either  living  or  killed  in  various  ways,  or  from  normal  tissue, 
is  sufficient  evidence  that  confidence  has  now  been  lost  in  the 
emplopnent  of  bacteriological  products  pure  and  simple.  Those 
who  have  had  the  widest  experience  with  the  immunity  reac- 
tions to  cancer,  as  these  have  been  studied  and  revealed  in  ani- 
mals in  the  laboratory,  have  notably  abstained  from  making 
any  claims  that  the  procedures  they  describe  have  any  thera- 
peutic value.  This  in  itself  should  suffice  as  a  warning  that 
therapeutic  endeavors  made  by  individual  and  isolated  workers 
are  liable  to  errors  which  can  be  avoided  or  allowed  for  in  the 
larger  centers  of  research.  In  the  present  state  of  knowledge 
it  is  of  course  to  be  expected  that  further  therapeutic  efforts 
will  continue  to  be  made  by  individuals  working  along  these 
lines,  and  thus  we  may  expect  to  see  almost  every  fresh  ad- 
vance in  the  laboratory  directed  to  therapeutic  ends,  however 
unjustifiable  they  may  be. 

In  regard  to  bacteriology  and  biotherapy  in  general  we  are 
at  the  present  time  witnessing  but  a  repetition  of  what  has 
gone  on  throughout  all  the  ages  in  the  search  for  a  remedy  for 
cancer.  This  fact  should  not  lead  to  the  conclusion  that  these 
efforts  are  not  honest.  But  despite  the  sincerity  of  pui-pose 
which  has  actuated  investigation,  the  results  which  have  been 
reported  are  unreliable,  and  will  continue  to  be  so  until  more 
is  learned  concerning  the  biology  of  the  tumor  cell,  and  until 
its  relation  to  the  individual  whose  life  it  is  destroying  is  ascer- 
tained. In  Section  VI  will  be  found  a  large  number  of  new 
facts  ascertained  in  the  laboratory  which  throw  out  of  account, 
as  empirical,  most,  if  not  all,  of  the  claims  yet  made  to  cure 
cancer  by  biotherapy. 


SECTION    XI 

SURGICAL   TREATMENT 

CHAPTER   I 

GENERAL  TEGHNIC  OF  SURGERY  AS  APPLIED  TO 

CANCER 

Tear  after  year,  in  lectures,  papers,  and  other  contributions, 
we  have  reviewed  certain  phases  of  the  cancer  problem,  en- 
deavoring always  to  emphasize  the  fact  that  from  remote  an- 
tiquity to  the  present  moment  the  only  method  of  treatment 
which  has  stood  the  test  of  time  is  surgical  removal  of  the  dis- 
eased tissue.  It  must  be  emphasized,  however,  that  the  surgery 
of  to-day  is  not  the  surgery  of  antiquity — that  it  is  scarce  fifty 
years  old,  and  that,  as  applied  to  cancer,  it  is  even  younger. 

Despite  the  fact  that  the  older  writers  advocated  thorough 
removal  "by  the  roots,"  it  is  quite  improbable  that  they  had 
any  clear-cut  conception  as  to  why  the  "roots"  of  cancer  should 
be  removed.  In  consequence  of  the  general  advance  in  ana- 
tomical and  histological  knowledge  surgeons  have  come  to  under- 
stand how  cancer  arises  in  a  small  area,  from  which  it  spreads 
to  other  parts  of  the  body,  to  comprehend  the  particular  sig- 
nificance of  certain  principles  of  surgery  with  reference  to  the 
nature  and  the  treatment  of  cancer,  and  to  evolve  the  applica- 
tion of  general  surgical  principles  to  the  special  requirements 
of  the  disease.  These  requirements  are  determined  by  the  oc- 
currence of  the  disease  in  different  parts  of  the  body.  They 
vary,  therefore,  for  anatomical  reasons,  or  because  of  the  greater 
or  less  risk  of  dissemination  from  one  site  or  organ  to  another. 

The  general  principles  of  surgical  technic  are  the  same,  of 
course,  no  matter  to  what  conditions  they  may  be  applied. 
There  are,  however,  certain  special  principles  which  apply  with 
enhanced  emphasis  to  surgery  as  employed  in  the  treatment  of 
malignant  disease.  Failure  to  observe  these  is  apt  to  be  fraught 
with  disappointment  to  the  surgeon  and  disaster  to  the  patient. 
They  may  be  considered  categorically  as  follows : 

345 


346  THE   CANCER   PROBLEM 

(1)  Thorough  sterilizatioyi  of  every  instrunieiit — knife,  re- 
tractor, or  needle — used  upon  the  skin  in  an  operation  for  can- 
cer of  the  skin  should  be  assured  before  it  is  used  for  any  other 
purpose.  As  the  operation  proceeds  the  same  instrument  should 
not  be  used  twice,  so  great  is  the  risk  of  auto-infection. 

We  may  or  may  not  accept  the  theory  of  the  contagiousness 
or  infectiousness  of  cancer  from  one  person  to  another,  but  it 
is  undoubtedly  true,  as  experiment  and  observation  have  com- 
pletely demonstrated,  that  the  disease  is  easily  transferable 
from  one  portion  of  a  cancerous  subject's  body  to  another  por- 
tion. According  to  experiments  made  by  the  Imperial  Cancer 
Research  Fund,  auto-transplantation  in  mice  succeeds  in  prac- 
tically 100  per  cent,  of  cases,  although  errors  of  technic  may 
cause  it  to  fall  to  90  per  cent.,  whereas  transplantation  from 
one  individual  to  another  (homologous  transplantation)  may 
not  succeed  once  in  five  hundred  trials,  although  the  condition 
is  most  favorable  and  the  technic  perfect. 

If  this  be  true,  continuing  the  dissection  with  the  knife  with 
which  the  skin  incision  over  a  malignant  tumor  has  been  made, 
may  lead  to  the  dissemination  of  the  cancer  cells  into  the  sur- 
rounding healthy  tissue. 

(2)  The  danger  of  auto-infection  must  be  obviated  by  the 
careful  preservation  of  nature's  barriers.  In  other  words,  a 
malignant  tumor  must  not  be  cut  into.  In  non-malignant  tu- 
mors and  other  operative  dissections  there  need  be  no  sacrifice 
of  healthy  tissue.  With  malignant  tumors,  or  those  suspected 
of  malignancy,  in  which  nature's  barriers  are  intact,  a  quarter 
to  a  half  inch  of  healthy  tissue,  according  to  location,  should  be 
removed,  if  possible,  along  with  the  growth.  This  obviates  the 
danger  of  liberating  cancer  cells  into  contiguous  blood  and 
lymph  channels,  or  into  the  surrounding  healthy  tissues. 

According  to  the  experimental  researches  of  Paine  and  Nich- 
olson,^ should  all  outlying  processes  of  cancer  have  been  suc- 
cessfully removed,  and  one  or  more  fragments  have  been  left 
loose  in  the  wound,  such  fragTaents  will  be  under  less  favorable 
conditions  than  those  of  the  tumor  left  in  organic  connection. 
Their  growth  will  be  retarded  until  they  have  become  connected 
with  the  surrounding  tissues  and  have  become  vascularized. 
Many  such  cells,  being  perhaps  already  of  advanced  cell-age, 
coming,  as  they  are  apt  to  do,  from  the  center  rather  than  from 
the  actively  growing  periphery  of  the  neoplasm,  may  die  be- 
fore this  vascularization  takes  place.  The  survivors,  however, 
will  eventually,  though  more  slowly,  form  definite  recurrences. 

1  Paine,  Alexander,  and  Nicholson,  G.  W. — ' '  Surgical  Interference  in 
Cancer,"  Brii.  Med.  Jour.,  July  22,  1911. 


GENERAL    TECHNIC  347 

This  is  one  of  the  explanations  of  the  difference  in  the  time  and 
virulence  of  recurrence  after  operation  for  early  cancer.  It 
emphasizes  with  great  force  the  call  for  the  careful  avoidance 
of  the  breaking  down  of  nature's  barriers. 

Some  surgeons  advocate  cutting  into  tumors  for  diagnostic 
purposes,  following  this  at  once  by  the  operation  or  by  the 
cauterization  of  the  surfaces  in  order  to  obviate  cell  implanta- 
tion or  dissemination.  This  is  permissible  as  a  preliminary 
procedure  for  procuring  sections  for  immediate  microscopic 
examination  when  it  is  proposed  to  proceed  to  more  extensive 
operation  if  found  necessary.  It  necessitates  extreme  care  and 
thoroughness;  otherwise  it  entails  an  added  risk. 

(3)  Clean-cut  hicisions,  and  as  little  tearing  and  pulling 
upon  the  tissues  as  possible,  should  be  the  invariable  rule. 

(4)  Complete  removal  of  early  accessible  cancer  is  always 
to  be  practiced,  unless  the  early  involvement  is  sufficiently  ex- 
tensive to  entail  elaborate  surgical  interference,  when  extreme 
age,  debility,  or  concurrent  disease  which  is  contraindicative 
to  surgical  procedure,  must  be  taken  into  consideration. 

Paine  and  Nicholson  ^  reported  a  series  of  interesting  ex- 
perimental studies  with  reference  to  metastasis  following  surgi- 
cal interference  in  cancer.  Their  observations  showed  con- 
clusively that  the  incomplete  removal  of  a  carcinoma  is  often 
followed  by  rapid  recurrence  of  a  greater  virulence  than  that 
of  the  original  tumor,  and  that  this  increase  in  the  virulence  is 
mainly  due  to  the  remaining  fragments  having  a  rich  blood 
supply.  This  larger  blood  supply,  in  their  opinion,  is  perma- 
nent, and  increases  as  the  cancer  cells  proliferate.  When  frag- 
ments of  cancer  tissue  are  left  in  situ,  with  the  blood  supply 
intact,  even  though  the  main  vessels  going  to  the  tumor  are 
properly  ligated,  those  which  supply  the  remaining  fragment 
will  promptly  dilate,  a  collateral  circulation  will  be  established, 
and  the  original  amount  of  blood  available  for  its  nutrition  will 
increase. 

(5)  Arterial  ligation,  for  purposes  other  than  the  immedi- 
ate control  of  hemorrhage,  may  be  mentioned  in  this  connection. 
The  special  method  of  starvation  ligation  with  lymphatic  block 
is  described  elsewhere  (see  Chapter  II,  p.  383). 

(6)  Operation  in  line  with  the  fascial  planes  has  been 
found  advantageous.  This  is  in  accordance  with  the  theory 
of  Handley,  who  holds  that  cancer  spreads  by  parietal  dissem- 
ination along  the  lymph  and  blood  channels  and  the  fascial 
planes. 

^  Loc.  cit. 


348  THE   CANCER   PROBLEM 

The  entire  subject  of  the  spread  of  cancer  in  the  individual 
is  discussed  elsewhere  (see  Section  XI,  Chapter  II),  and  need 
not  be  reiterated  in  this  connection.  It  is  important,  how- 
ever, to  bear  in  mind,  while  operating,  the  different  avenues 
of  extension,  and  to  plan  and  execute  the  surgical  procedure 
accordingly.  More  fascia  and  connective  tissue  should  be  re- 
moved than  skin,  even  in  the  excision  of  small  growths.  Fail- 
ure to  observe  this  point  of  technic  doubtless  accounts  for  many 
recurrences.     {Vide  infra,  paragraph  21.) 

(7)  All  wounds  in  surgery  should  be  so  placed  as  to  prevent 
future  irritation  by  the  scar.  This  is  applicable  to  general  sur- 
gery as  a  preventive  precaution,  in  accordance  with  the  theory 
of  the  etiological  significance  of  chronic  irritation  in  the  pro- 
duction of  cancer.  It  is  of  even  greater  importance  in  surgery 
as  applied  to  cancer,  the  subject  being  already  predisposed  to 
recurrence,  and  hence  more  susceptible  to  the  influence  of  irri- 
tation. A  flap  over  the  patella,  for  example,  should  be  round 
or  curved,  in  line  with  natural  folds  and  wrinkles  of  the  skin, 
instead  of  straight  across;  and  in  the  neck  the  incision  should 
be  in  line  with  natural  creases. 

In  removing  a  non-ulcerated  tumor  from  the  breast,  the  in- 
cision should  be  made  along  the  lower  margin  of  the  gland. 
The  cosmetic  effect  is  thus  far  better  than  when  the  skin  over 
the  breast  is  incised. 

(8)  All  manipulations  of  a  tumor  and  of  cancer-bearing 
tissue  should  be  made  with  a  care  even  greater  than  in  other 
surgical  procedures,  in  order  to  prevent  the  accidental  milking 
out  of  cancer  cells  into  surrounding  healthy  tissue  or  into  sev- 
ered lymph  and  blood  channels.  Local  recurrence  and  metas- 
tatic development  may  undoubtedly  be  fostered  by  failure  to 
observe  this  point  in  the  technic  of  surgery  as  applied  to  cancer. 

In  this  connection  Tyzzer  ^  has  made  some  interesting  and 
valuable  observations  upon  waltzing  mice,  which  he  summar- 
ized as  follows : 

"Operations  incomplete  but  involving  the  incision  of  im- 
planted tumors  do  not  increase  the  incidence  of  metastases,  but 
these  grow  more  rapidly  as  the  result  either  of  an  increase  in 
the  amount  of  food  material  made  available  by  the  removal  of 
a  large  mass  of  tumor  tissue  elsewhere  (athrepsia)  or  of  the 
elimination  of  the  element  of  cachexia  and  improvement  of  the 
physical  condition  which  almost  invariably  occurs. 

''Radical  operations  involving  the  removal  of  all  the  tumor — 
except  minute  masses  which  subsequently  come  into  evidence 

^  Tyzzer,  E.  E. — ' '  Factors  in  the  Production  and  Growth  of  Tumor 
Metastases,"  Jour,  of  Medical  Besearch  (N.  S.  23),  Vol.  28,  1913,  p.  309. 


GENERAL    TECHNIC  349 

along  the  path  of  the  iuoculating  trocar — if  performed  just 
prior  to  the  period  in  which  metastasis  commenced,  result  in  a 
temporary  freedom  from  this  complication,  even  though  recur- 
rence commonly  occurs. 

"Metastasis  may  be  artificially  produced  by  the  manipulation 
and  massage  of  the  implanted  tumor.  This  is  accomplished  as 
readily  during  the  early  development  of  the  tumor  as  in  the 
period  in  which  metastasis  naturally  occurs. 

"The  production  of  metastases  is  dependent  on  certain  dem- 
onstrable factors — the  biological  character  of  the  tumor,  the 
duration  of  its  growth,  the  size  of  the  primary  mass,  possibly 
peculiar  conditions  furnished  by  the  host  tissues,  and,  under 
artificial  conditions,  forcible  manipulation. 

"The  so-called  'pre-metastatic  period'  is  better  accounted  for 
by  an  absence  of  the  conditions  necessary  for  the  dissemination 
of  tumor  cells  than  by  a  phase  of  'active  resistance'  during 
which  the  further  development  of  tumor  emboli  is  prevented. 
By  the  early  artificial  dissemination  of  tumor  cells  by  the  ma- 
nipulation of  the  primary  tumor,  this  period  may  be  greatly 
shortened." 

The  results  of  these  investigations,  according  to  Tyzzer,  find 
practical  application  in  the  management  of  tumor  patients. 
He  says:  "They  are  of  such  character  that  every  physician 
should  realize  the  irreparable  harm  which  may  result  from  the 
manipulation  of  malignant  tumors  in  their  early  development. 
Although  the  present  observations  are  made  on  a  tumor  with 
which  dissemination  usually  takes  place  by  way  of  the  blood 
stream,  it  seems  reasonable  to  expect  similar  results  with  human 
tumors  which  become  disseminated  by  way  of  the  lymphatics. 
The  course  of  procedure  to  which  the  patient  is  frequently  sub- 
jected, as  I  have  repeatedly  observed — the  palpation  of  the 
mass  in  question  in  repeated  physical  examinations,  the  violent 
scrubbing  often  employed  in  preparing  the  field  of  operation — 
is  almost  identical  with  that  which  I  have  employed  for  the 
experimental  production  of  metastases.  It  would  be  of  advan- 
tage to  the  patient  if  each  questionable  tumor  of  the  breast,  for 
example,  could  be  regarded  as  a  high  explosive,  the  least  ma- 
nipulation of  which  should  be  absolutely  avoided  both  prior  to 
and  during  the  operation.  It  is  not  improbable  that  by  this 
means  metastasis  and  extension  beyond  the  field  of  operation 
could  be  prevented  and  the  percentages  of  cases  cured  by  opera- 
tion increased.  From  the  point  of  view  of  metastasis  it  would 
appear  from  these  results  much  less  serious  to  cut  into  a  tumor 
than  to  exert  pressure  upon  it,  although  the  effect  of  the  dis- 
tribution of  tumor  tissue  throughout  an  extensive  operation  is 


350  THE   CANCER   PROBLEM 

quite  naturally  understood.  It  is  not  improbable  that  the  re- 
moval of  a  tumor  of  large  size  from  which  metastasis  has 
already  occurred  results  in  a  more  rapid  growth  of  the  secon- 
dary deposits.  This  should  not  weigh  too  heavily,  however,  in 
considering  palliative  operations  of  this  sort,  for  internal  tu- 
mors not  being  under  the  direct  observation  of  the  patient 
furnish  a  less  constant  source  of  apprehension,  and  the  removal 
of  a  large  external  tumor  may  make  the  case  much  easier  for 
the  physician  to  manage." 

(9)  Lymph  glands  and  vessels  contiguous  to  the  diseased 
area  shoidd  be  removed,  en  masse,  if  possible. 

(10)  Lymph  glands  more  remotely  situated,  as  in  the  su- 
praclavicular region  or  in  the  axilla,  in  breast  cancer,  should  be 
removed,  if  possible,  before  the  primary  tumor  is  excised. 

(11)  Dissection  of  lymphatic  or  other  structures  should  be 
made  toward,  not  away  from,  the  tumor.  It  is  a  grave  error 
of  surgical  technic,  not  uncommonly  committed,  to  remove  a 
non-ulcerated  cancerous  breast,  for  example,  by  a  sweeping 
circular  incision,  and  then  to  work  out  from  this  area,  up  into 
the  clavicular  region,  out  into  the  axilla,  and  down  over  the 
thorax,  with  a  distinct  possibility  of  the  infection  of  the  area 
from  which  the  tumor  has  just  been  removed.  The  procedure 
should  be  reversed — the  glands  and  all  outlying  tissues  to  be 
removed  should  be  excised  first,  before  the  tumor  is  touched. 
In  this  way  the  probability  of  auto-infection  is  markedly  les- 
sened, and  hence  the  danger  of  local  recurrence  and  remote 
metastasis  is  decreased. 

(12)  Raw  surfaces  in  ulcerated  cancer  should  receive 
proper  care  before  and  during  operation.  When  the  skin  over 
the  cancer  is  ulcerated  the  danger  of  pyogenic  infection  during 
the  operation  is  very  great.  This  may  be  largely  avoided  by 
preliminary  care  of  the  raw  surface.  A  few  days  of  antiseptic 
treatment  will  often  be  sufficient  to  make  a  fetid  ulcer  fairly 
clean.  At  times  of  operation  the  local  use  of  strong  nitric  acid, 
or  actual  cautery,  is  of  advantage.  Some  surgeons  ablate  the 
ulcer  and  neighboring  tissue  immediately  before  the  operation, 
as  the  safest  method. 

(13)  Severed  lymph  vessels  should  not  be  left  open,  but 
should  be  tiuisted  off  in  order  to  prevent  further  lymphatic 
permeation,  after  lymph  glands  and  vessels  have  been  removed 
as  far  as  it  is  possible  to  go.  The  possibility  of  irritation  by 
this  method  is  no  greater  than  by  closing  the  vessels  by  means 
of  ligatures,  and  is  not  so  prolonged.  Furthermore,  the  twist- 
ing is  more  quickly  and  more  easily  accomplished  than  the 
ligation. 


GENERAL    TECHNIC  351 

(14)  Subsequent  irritation  of  the  tissues  to  he  left  in  situ 
should  be  prevented  in  every  way  possible  by  special  precau- 
tions during  operation.     {Vide  infra,  15,  16,  17,  18,  and  19.) 

(15)  Hot  towels  should  be  used  as  extensively  as  possible 
to  control  capillary  oozing  and  bleeding  from  small  vessels, 
thus  largely  obviating  the  crushing  or  bruising  of  tissues  by  the 
use  of  clamps.  Some  operators  leave  the  clamps  on  the  vessels 
for  a  long  time,  with  the  shank  pressing  against  the  soft  tis- 
sues. The  use  of  one  hundred  and  fifty  clamps  in  the  course 
of  an  operation  means  the  maceration  of  two  handsful  of  tissue, 
and  the  leaving  of  this  devitalized  organic  material  in  the 
wound. 

(16)  When  it  is  necessary  to  ligate  vessels  the  question  of 
subsequent  irritation  must  be  borne  in  mind.  Instead  of  heavy, 
non-absorbable  ligature  material,  fine  catgut  dipped  in  physi- 
ological salt  solution,  or  fine  linen  paraffined,  will  control  the 
vascularity,  insuring  at  the  same  time  a  softer  and  more  pliable 
foreign  body  in  the  tissues,  thus  giving  rise  to  less  irritation. 
Through  the  skin  paraffined  silk  or  linen  will  prove  effectual 
in  controlling  capillary  oozing,  and  will  be  practically  non- 
irritating.  The  knot  should  lie  between  the  point  of  puncture 
and  the  line  of  incision. 

(17)  Drainage  tubes,  which  are  prolific  sources  of  irrita- 
tion, should  be  used  as  little  as  possible.  If  the  wound  cannot 
be  closed,  rubber  tissue  may  often  be  substituted  for  drainage 
tubes.  When  tubes  are  employed  they  should  be  made  of  rub- 
ber and  placed  where  they  are  least  apt  to  cause  irritation. 

(18)  Tension  upon  the  wound  is  always  to  be  avoided,  but 
particularly  so  in  cancer  subjects,  because  of  subsequent  irri- 
tation in  the  scar.  In  placing  retention  stitches  care  must  be 
taken  not  to  exert  undue  pull  at  any  point. 

(19)  A  pad  of  uninjured  fat  should  always  be  left,  if  pos- 
sible, to  prevent  the  skin  from  lying  over  hard,  unyielding,  or 
bony  surfaces.  Fat  serves  as  nature's  buffer,  and  prevents 
future  irritation  and  discomfort;  it  may  also  help  to  ward  off 
recurrence. 

(20)  The  primary  tumor,  the  lymphatic  vessels  and  glands, 
and  the  intervening  tissues  should  be  removed,  as  a  ride,  at  one 
operation.  It  is  sometimes  advantageous,  as  in  cancer  of  the 
tongue  or  buccal  cavity,  where  it  is  impossible  to  work  in  a 
sterile  field,  to  remove  the  glands  at  a  subsequent  operation. 
Auto-infection  can  be  more  definitely  prevented  in  this  way. 
Often,  in  cases  where  the  mucous  membrane  is  involved,  one 
must  deal,  not  only  with  the  tumor,  but  with  mixed  infection. 
If  the  mucous  membrane  of  the  mouth  receive  infection  first, 


352  THE   CANCER   PROBLEM 

in  some  oi  these  cases  the  glands  of  the  neck  may  be  more  easily 
and  safely  removed  later.  On  the  other  hand,  if  the  glands  are 
well  defined,  and  if  there  is  no  evidence  of  mixed  infection,  it 
is  better  to  go  low  down,  for  example,  in  the  neck  first,  and 
work  up,  operating  in  the  mouth  later. 

(21)  The  extent  of  the  shin  incision  involves  an  important 
point  in  cancer  surgery  concerning  which  there  is  still  diver- 
gence of  opinion.  Some,  with  Halsted,  prefer  to  remove  the 
skin  in  breast  cancer,  closing  even  extensive  wounds  by  means 
of  skin-grafts.  Others  agree  with  Watson-Cheyne,  who  rarely 
removes  enough  skin  to  necessitate  grafting.  The  fact  that 
Che;)Tie's  statistics  show  a  smaller  percentage  of  skin  recur- 
rences than  do  Halsted's  is  doubtless  due  to  the  fact  that  the 
former  makes  a  more  thorough  dissection  of  the  fascia.  Rod- 
man considers  any  breast  operation  incomplete  in  which  the 
fascia  is  not  removed  down  to  and  including  several  inches  of 
the  rectus  sheath. 

(22)  Strong  antiseptic  solutions  should  not  he  used  in  can- 
cerous wounds,  because  of  the  danger  of  irritation  and  inflam- 
mation, with  the  possibility  of  undue  contraction  of  the  wound. 

(23)  In  general  surgery  it  is  important  to  keep  the  hand 
as  much  as  possible  out  of  the  wound.  In  cancer  surgery  it  is 
equally  important,  at  times,  to  put  the  hand,  gloved  or  un- 
gloved, into  the  wound,  for  the  purpose  of  carefully  examining 
the  tissues  for  possible  nodules  of  cancer  which  cannot  be  de- 
tected by  the  eye.  Care  must  always  be  exercised,  in  making 
such  examination,  not  to  manipulate  the  tissues  roughly,  thus 
causing  undue  injury  or  adding  to  the  danger  of  cancer-cell 
dissemination. 

(24)  Small  knots  of  ligatures  may  resemble,  in  feeling, 
minute  cancerous  nodules.  The  extent  of  the  disease  is  better 
determined  before  the  ligation  of  the  vessels  is  done. 

(25)  In  sponging  a  wound  the  rule  of  general  surgery 
which  calls  for  the  patting  rather  than  the  rubhing  of  the  sur- 
faces is  doubly  important  in  cancer  masses. 

(26)  Tourniquets  should  be  avoided  in  the  surgery  of  can- 
cer because  of  the  danger  of  massaging  cancer  cells  into  the 
blood  current.  There  is  no  danger  of  their  dissemination  in 
this  way  above  the  point  of  application,  but  there  is  danger  of 
forcing  such  cells  out  into  the  surrounding  tissues,  and  into  the 
blood  and  lymph  vessels  below.  This  does  not  apply,  of  course, 
in  amputations. 

(27)  Scar  tissue  should  be  reduced  to  a  minimum  over  the 
site  where  cancer  is  most  apt  to  manifest  itself  in  local  recur- 
rence. 


TECHNIC  OF  SURGERY  AS  APPLIED   TO  CANCER  353 

(28)  Absolute  approximation  of  the  edges  of  the  wound  is 
important.  If  this  cannot  be  done,  leave  open  that  part  which 
is  farthest  removed  from  the  point  at  which  local  recurrence 
is  most  apt  to  appear,  or  make  an  incision  at  a  short  distance, 
sliding  the  tissues  over  so  as  to  close  the  original  wound. 

(29)  //  it  is  necessary  to  leave  a  part  of  the  vjound  to 
granulate  this  should  not  be  covered  with  gauze,  which  is  harsh 
and  stiff,  but  with  old,  soft  linen,  or  with  narrow  strips  of  rub- 
ber tissue,  which  easily  takes  the  configuration  of  the  surface 
covered,  and  thus  protects  from  mechanical  irritation. 

(30)  The  granulation  area,  if  large,  should  be  kept  soft 
by  means  of  ointment.  A  useful  agent  is  one-half  of  one  per 
cent,  zinc  oxid  ointment  in  lanolin. 

(31)  Preliminary  cathetarization  of  the  ureters,  the  cathe- 
ters being  left  in  situ,  may  be  important  in  cancer  of  the  uterus. 
Some  claim  (1)  that  it  renders  their  isolation  less  difficult  and 
more  quickly  accomplished;  (2)  that  it  aids  in  the  control  of 
hemorrhage;  (3)  and  that  it  lessens  the  liability  to  injury  of 
the  ureter,  or  to  its  ligation  by  mistake,  in  the  Bainbridge 
method  of  arterial  ligation  with  lymphatic  block.  I  have  rarely 
found  preliminary  catheterization  necessary.  It  adds  to  the 
technic  and  increases  the  dangers.  If  employed  it  must  be  re- 
membered that :  (a)  extreme  care  should  be  used  not  to  unneces- 
sarily manipulate  the  ureters  either  before  or  after  removal  of 
the  catheters;  (b)  usually  there  is  a  purulent  vaginal  discharge, 
and  the  danger  of  bladder  infection  must  be  carefully  guarded 
against;  (c)  if  any  difficulty  is  encountered  in  the  passage  of 
the  catheter  it  must  be  withdrawn  at  once;  (d)  in  advanced 
cancer  the  ureters  are  sometimes  pressed  upon  by  inflammatory 
adhesions,  or  their  course  may  be  somewhat  altered;  (e)  the 
irritation  caused  by  leaving  the  catheters  in  situ  will,  in  the 
presence  of  cystitis,  tend  to  carry  infection  into  the  kidneys. 

PTTEPOSES   OF    THE    SURGICAL   TREATMENT    OF    CANCER 

Surgery,  in  its  application  to  malignant  disease,  aims  at  the 
following  definite  ends,  according  to  the  circumstances  of  the 
case: 

(1)  Prevention,  through  the  removal  of  benign  growth? 
and  other  tissue  formations  which,  under  certain  conditions, 
predispose  to  the  development  of  cancer.     (See  Section  VIII.) 

(2)  Diagnosis.  Surgery  may  be  brought  into  requisition 
for  diagnostic  purposes  under  the  following  circumstances: 

(a)  In  the  precancerous  conditions  discussed  in  Section. 
VII. 


354  THE   CANCER   PROBLEM 

(b)  When  the  clinical  symptoms  have  not  begun  to  mani- 
fest themselves,  except  by  tumor-formation — a  mere  painless 
lump — as  in  the  early  stages  of  cancer  in  almost  any  locality. 

(c)  When  the  clinical  symptoms  are  not  sufficiently  well 
marked  to  warrant  radical  surgical  intervention,  or  where  the 
patient  refuses  it. 

(d)  In  certain  obscure  abdominal  conditions  in  which  ex- 
ploratory laparotomy  is  necessary  in  order  to  establish  a  diag- 
nosis.    (See  Section  VII,  Chapter  III.) 

(3)  Early  and  Complete  Removal — Cure. — So  much  ex- 
perimental and  clinical  evidence  has  been  adduced  within  the 
past  decade  to  prove  the  purely  local  origin  of  cancer  that  it 
seems  hardly  necessary  to  refer  to  the  matter  in  this  connec- 
tion. It  may  be  said,  however,  that  there  are  still  some  mem- 
bers of  the  profession  who  speak  and  write,  particularly  to 
la;^Tnen,  upon  the  subject  of  cancer  as  a  general  disease  with 
local  manifestations.  It  is  not  to  be  forgotten,  furthermore, 
that  cancer  comes  under  the  head  of  "Diseases  of  Diathetic 
Origin,"  in  the  Index  Medicus,  that  valuable  periodical  cata- 
logue of  medical  literature  which  emanates  from  the  Library 
of  the  Surgeon  General's  Office. 

But  by  those  in  touch  with  recent  scientific  investigation 
it  is  no  longer  believed  that  in  cancer  the  system  is  permeated 
by  something  of  which  the  manifest  cancer  is  but  an  "out- 
crop" like  the  mushroom  from  the  mycelium  underground. 
The  process  is  in  reality  exactly  the  reverse.  The  com- 
monly accepted  opinion  is  that,  whatever  may  be  the  essen- 
tial cause  of  cancer,  the  disease  begins  as  a  purely  local  and 
entirely  removable,  hence  curable,  pathological  manifestation, 
the  dissemination  spreading  from  the  primary  area.  There 
are  doubtless  underlying  systemic  conditions  favoring  malig- 
nancy, but  essentially  it  seems  to  be  a  local  process.  Surgery, 
therefore,  in  its  application  to  the  treatment  of  cancer  in  this 
stage,  must  be  performed  with  reference  (1)  to  the  general 
condition  of  the  patient;  (2)  to  the  possibility  of  thorough 
and  complete  removal;  (3)  to  the  prevention  of  recurrence. 

In  view  of  the  fact,  that  in  the  earlier  or  so-called  removable 
stages  of  cancer,  failure  to  completely  eradicate  the  diseased 
tissue  means  inevitable  recurrence  sooner  or  later ;  and  further 
of  the  fact  that  even  removable  cancer  sometimes  calls  for  very 
extensive  dissections  in  order  to  prevent  recurrence,  the  con- 
dition of  the  patient,  as  well  as  his  wishes  or  those  of  his  rela- 
tives, must  be  taken  into  consideration.  If  there  are  no  contra- 
indicative  conditions  such,  for  example,  as  extreme  age,  debil- 
ity, or  serious  heart  and  kidney  lesions,  and  if  the  patient  pre- 


GENERAL    TECHNIC  355 

fei's  the  surgical  and  functional  risks  to  possible  recurrence  of 
cancer  and  ultimate  death  from  the  disease,  no  other  course 
should  receive  consideration.  Ruthless  sacrifice  of  nerve  and 
muscle,  or  other  tissue,  is  certainly  to  be  condemned,  particu- 
larly unnecessary  mutilation,  and  impairment  or  destruction  of 
function.  Just  how  far  to  go  in  the  removal  of  cancer  or  cancer- 
bearing  tissue  is  a  question  of  the  utmost  importance.  Even 
the  most  experienced  operator  cannot  always  recognize  that  fine 
line  of  distinction  between  diseased  and  normal  tissue,  ability 
to  judge  of  which  constitutes  the  imponderable,  unteachable 
element  of  diagnostic  skill  that  comes  only  with  long  and  care- 
ful observation. 

(4)  Removal  of  advanced  cancer,  making  possible  the  ap- 
plication of  special  methods  of  treatment. 

(5)  Treatment  of  irremovable  and  incurable  cancer,  mak- 
ing possible  the  application  of  special  methods  of  treatment  and 
the  relief  of  special  symptoms.     (See  Section  XII.) 

SUMMARY 

The  classical  principles  of  operative  technic  are  as  applicable 
to  cancer  as  to  any  other  disease  requiring  surgical  intervention. 
When  the  application  of  the  special  principles  outlined  above 
becomes  universal  among  surgeons  who  operate  upon  patients 
with  cancer  there  will  follow  a  marked  reduction  in  the  propor- 
tion of  cases  in  which  recurrence  takes  place,  and  in  the  num- 
ber of  cases  in  which  the  disease  terminates  in  death. 


CHAPTER    II 
SPECIAL   TECHNIC 

No  attempt  is  made  in  this  volume  to  cover  the  general  sub- 
ject of  surgical  technic  as  applied  to  cancer.  There  are,  how- 
ever, certain  modifications  of  technic,  and  numerous  special 
procedures,  applicable  chiefly  to  irremovable  cancer,  which 
may  be  appropriately  considered  in  this  chapter.  Operations 
which  are  fully  described  in  the  text-books  on  general  surgery 
are  not  given  in  detail. 

Various  factors  determine  the  modification  or  the  evolution 
of  the  given  surgical  procedure.  In  some  instances  the  pur- 
pose is  the  correction,  as  nearly  as  may  be  possible,  of  defects 
caused  by  the  ravages  of  the  disease  or  by  the  radical  removal 
thereof.  Illustrations  of  this  may  be  found  in  the  various 
plastic  operations,  such  as  rhinoplasty,  cheiloplasty,  and  skin- 
grafting.  In  another  class  of  operations  the  technic  is  modified 
in  accordance  with  some  particular  theory  concerning  the  origin 
or  spread  of  cancer.  An  illustration  of  this  is  found  in  the 
modified  breast  and  rectal  operations  in  line  with  Handley's 
"permeation  theory"  of  cancer  dissemination.  In  others  the 
operation  is  entirely  palliative  in  its  purpose,  being  designed 
to  relieve  pain,  to  control  hemorrhage,  to  correct  obstruction, 
or  to  alleviate  other  symptoms  which  result  from  advanced 
cancer.  Examples  of  this  class  of  procedures  may  be  found, 
among  others,  in  arterial  ligation,  lymphangioplasty,  and  neu- 
rectomy. 


A.     SURGICAL  TECHNIC  BASED  UPON  THE  "PERMEATION  THEORY" 
OF  CANCER  DISSEMINATION 

Handley,  with  whose  name  the  permeation  theory  of  the 
dissemination  of  cancer  is  usually  associated,  has  said:^  "To 
some  of  my  colleagues  the  very  word  'theory'  may  suggest  a 

^  Handley,  W.  Sampson. — * '  Eecent  Advances  in  the  Surgical  Treatment 
of  Some  Forms  of  Cancer,"  The  Universal  Medical  Becord,  1912,  V,  pp. 
385-406. 

356 


SPECIAL  TECHNIC  357 

repellent  remoteness  from  practical  affairs,  to  others  it  may 
connote  merely  a  fabric  of  cerebral  cobwebs."  "The  major- 
ity," he  continues,  "while  quite  willing  to  consider  the  views 
placed  before  them,  will  at  once,  and  quite  rightly,  ask :  'What 
are  the  new  facts  upon  which  this  theory  is  based,  and  what  is 
its  practical  importance  to  me  in  my  surgical  work  V  " 

In  answering  these  questions  Handley  has  demonstrated 
satisfactorily  to  many  that  his  theory  has  a  strictly  practical 
bearing  upon  surgical  technic  as  applied  to  cancer,  particularly 
to  cancer  of  the  breast. 

For  the  benefit  of  those  who  are  not  familiar  with  it,  a  brief 
review  of  the  permeation  theory  is  given,  together  with  the 
work  which  led  up  to  it. 

In  1889,  Heidenhain  ^  published  his  well-known  researches 
on  breast  cancer,  which  were  based  upon  the  most  careful  and 
thorough  examination  of  thirteen  excised  breasts,  by  means  of 
many  thousands  of  microscopic  sections.  Heidenhain  thus 
sunmaarizes  the  result  of  his  researches: 

"(1)  The  pectoral  fascia  is  extraordinarily  thin,  and  its 
limits,  especially  in  stout  women,  are  very  ill-defined.  So  that 
it  cannot  be  dissected  away  from  the  muscle  without  leaving 
behind  fragments  of  it,  unless  one  actually  removes  the  surface 
of  the  muscle. 

"(2)  In  thin  women  the  substance  of  the  breast,  and  in 
stouter  ones  at  least  some  lobules  of  it,  are  intimately  con- 
nected with  the  fascia  and  so  with  the  muscle,  so  that  in  am- 
putation not  carried  through  the  muscle,  portions  of  the  gland 
are  easily  left  behind. 

"(3)  A  breast  in  which  cancer  nodules  are  present  is  dis- 
eased very  widely  and  perhaps  in  its  whole  extent.  The  epi- 
thelial cells  of  the  acini  proliferate,  and  simultaneously  the 
periacinous  connective  tissues  increase  in  amount.  In  the 
lymph  vessels  of  the  breast,  along  considerable  stretches,  epi- 
thelial cells  are  embolized  (Langhans). 

"(4)  In  the  retro-mammary  fat,  lymph  vessels  run  from 
the  gland  to  the  fascia,  usually  in  company  with  blood  vessels. 
In  two-thirds  of  cases  of  breast  cancer  numerous  little  cancer- 
ous metastases  are  found  in  these  lymph  vessels.  The  epithelial 
growth  advances  along  these  preformed  channels,  even  through 
thick  layers  of  fat,  quickly  to  the  fascia. 

"(5)  The  pectoralis  major  is  generally  unattacked  so  long 
as  the  carcinoma  is  freely  movable  over  it.  It  first  becomes 
diseased  when  a  metastatic  nodule  on  the  fascia,  growing  inde- 

1  Heidenhain,   D.    L. — * '  Ueber    die   Ursacher    der   lokaler    Krebsrecidive 
nach  Amputation   Mammas, "   Langenbeclc's  ArcMv,   1889. 


358  THE   CANCER   PROBLEM 

pendently,  advances  into  it,  or  when  the  primary  tumor  infects 
it  by  its  growth  in  continuity.  Probably  in  the  muscle  also 
cancer  spreads  first  by  the  l^anph  channels  and  from  these 
insinuates  itself  between  the  muscle  fibers. 

"(6)  It  is  probable  that  during  contraction  of  the  muscle 
epithelial  cells  are  distributed  through  the  muscle  with  the 
lymph  stream.  Thus  a  muscle  attacked  by  cancer  must  be  sus- 
pected in  its  whole  extent." 

In  the  final  section  of  his  paper  Heidenhain  remarks: 

"Accurate  and  systematic  studies  on  the  channels  of  spread 
of  cancer  in  secondarily  affected  organs  (skin,  fat,  muscles, 
bones,  etc.)  might  be  of  extraordinary  value.  My  own  obser- 
vations upon  the  spread  of  breast-cancer  in  the  pectoral  muscle 
show  in  what  way  I  consider  such  researches  would  be  prac- 
tically valuable.  But  enough  of  speculations!  It  is  sufficient 
to  have  called  attention  to  this  entirely  unknown  region." 

In  1899  Stiles,-^  of  Edinburgh,  from  the  examination  of  over 
one  hundred  breasts  removed  by  operation,  modified  and  ex- 
tended the  conclusions  of  Heidenhain.  Stiles  insisted  on  the 
removal  of  the  whole  breast  to  its  remotest  periphery,  not  be- 
cause he  shared  Heidenhain's  view  that  any  mammary  epithe- 
lium left  would  be  likely  to  become  cancerous,  but  because  only 
thus  could  the  whole  lymphatic  system  of  the  breast  be  extir- 
pated. Recurrence,  in  Stiles'  view,  is  likely  to  occur  in  over- 
looked portions  of  breast  tissue  "from  cancerous  emboli  lurking 
in  the  Ijonphatics"  of  the  unexcised  portion  of  the  breast,  and 
in  two  cases  he  showed  this  view  to  be  correct.  He  recognized 
that  such  cancerous  emboli  might  be  found  beyond  the  limits  of 

*  Stiles,  Harold  Jalland. — ' '  On  the  Dissemination  of  Cancer  of  the 
Breast,"  Brit.  Med.  Jour.,  1899,  Vol.  I,  p.   1452. 

See  also: 

Stiles:  "The  Surgical  Anatomy  of  the  Breast  and  Axillary  Lymphatic 
Glands  considered  with  reference  to  the  morbid  anatomy  and  treatment  of 
carcinoma:  with  a  note  on  the  'nitric  acid  method'  of  demonstration," 
Trans.  Med.  Chir.  Soc.  Edinb.,  1891-2,  n.  s.  XI,  37-70,  2  pi.;  Edinburgh 
Med.  Journal,  1892-3,  XXXVIII,  26. 

"Carcinoma  of  the  Mamma,"  Brit.  Med.  Jour.,  1892,  II,  673. 

The  Eoyal  College  of  Surgeons  of  England,  at  a  quarterly  meeting  of 
the  Council  on  April  9,  1896,  awarded  the  Walker  Prize  to  Stiles  for  work 
done  within  the  five  years  ending  on  December  31,  1895.  According  to 
the  Lancet,  April  18,  1896,  "the  work  done  by  Mr.  Stiles  appeared  to  be 
most  noteworthy  of  the  prize,  on  the  ground  that  he  had  investigated  most 
minutely  the  morbid  anatomy  of  cancer,  its  mode  of  spread,  its  relation  to 
the  organ  in  which  it  originates,  and  its  relation  to  the  lymphatic  system 
of  the  part.  His  work  on  the  pathological  anatomy  of  the  female  breast 
and  its  accessory  portions  appears  to  be  especially  valuable  from  the  fact 
that  it  has  been  able  to  demonstrate,  by  his  nitric  acid  method,  that  the 
mammary  acini  have  a  much  wider  distribution  than  has  hitherto  been 
described.  The  importance  of  this  in  the  determination  of  the  extent  of 
operative  procedure  is,  of  course,  very  great. ' ' 


SPECIAL   TECHNIC  35.9 

the  breast.  ''The  principle,  therefore,  which  should  underlie 
all  operations  for  carcinoma  of  the  mamma  is  the  removal,  not 
only  of  the  breast,  but  also  of  as  much  of  the  surrounding^  tissue 
as  is  likely  to  contain  the  lymphatics  along  which  cancer  cells 
may  be  disseminated." 

Stiles  next  discussed  spread  along  the  lymphatics,  and  figured 
"paravascular  lymphatics  distended  by  cancer  cells."  He  goes 
on  to  say :  "Having  gained  the  lymph  vessels,  a  few  cells  may 
at  any  time  be  transplanted  by  the  lymph  stream  to  a  lymphatic 
gland,  or  may  be  arrested  by  emboli  at  any  point  along  the 
lymph  channel  which  leads  to  the  lymphatic  gland." 

Although  Stiles  demonstrated  that  the  paralobular,  para- 
ductal,  interlobular,  and  paravascular  lymphatics  may  be  in- 
jected as  it  were  by  cancer  cells,  he  did  not  appreciate  the  sig- 
nificance of  his  observations  with  respect  to  the  general  theory 
of  dissemination.  He  says :  "It  must  not  be  supposed,  however, 
that  in  carcinomatous  mammae  the  lymphatics  throughout  the 
gland  are  extensively  and  continuously  filled  with  cancer  cells ; 
in  some  breasts  .  .  .  emboli  are  numerous;  in  others  sections 
from  many  parts  of  the  gland  have  to  be  examined  before  any 
emboli  can  be  discovered ;  in  others  again  careful  search  fails  to 
find  them." 

It  was  apparently  on  account  of  these  difiiculties  that  Stiles 
remained  an  advocate  of  the  embolic  theory  of  dissemination. 
The  detection  of  the  process  of  perilymphatic  fibrosis  by  Hand- 
ley  supplied  the  explanation  of  these  anomalous  facts. 

With  regard  to  the  spread  of  cancer  in  the  extramammary 
structures.  Stiles  believed  that  by  his  nitric  acid  method  he 
could  demonstrate  the  spread  of  cancer  in  the  skin.  He  also 
demonstrated  cancerous  paravascular  lymphatics  in  the  con- 
nective tissue  septa  joining  the  skin  to  the  mamma.  He  next 
referred  to  the  frequency  of  invasion  of  the  lymphatics  of  the 
pectoral  fascia,  and  insisted  on  the  necessity  for  removing  a 
large  area  of  this  fascia. 

Stiles  concluded  his  paper — a  most  valuable  and  original 
one — by  a  very  full  and  accurate  study  of  the  invasion  of  the 
axillary  glands  in  breast  cancer. 

Watson-Cheyne,  basing  his  operative  practice  upon  the  con- 
clusions of  Stiles,  brought  about  a  great  improvement  in  the 
results  of  the  operative  treatment  of  breast  cancer  in  England. 
His  operation  differed  from  that  of  Halsted  in  that  he  widened 
the  skin  flaps  extensively  and  removed  a  large  area  of  the  deep 
fascia. 

Until  1909  all  the  investigations  on  breast  cancer  had  been 
performed  upon  the  excised  breast.     The  embolic  theory  re- 


560  THE   CANCER   PROBLEM 

mained  the  only  one  stated  in  the  text-books  as  accounting  for 
the  dissemination  of  breast  cancer,  and  the  observations  of 
Heidenhain  and  Stiles  on  the  spread  of  growth  by  continuity 
along  the  lymphatics  appeared  even  to  these  observers  to  have 
no  relation  to  the  question  of  systemic  dissemination,  important 
as  they  were  with  regard  to  the  question  of  local  spread. 

Professor  Depage,^  of  Brussels,  reviewing  the  subject  of 
breast  cancer  before  the  International  Society  of  Surgery,  in 
1908,  stated  truly  that  the  embolic  theory  of  cancerous  dis- 
semination had  never  been  demonstrated,  and  that  it  had  held 
its  ground  partly  by  its  attractiveness  as  an  idea,  and  partly 
because  it  had  no  serious  rival.  It  is  particularly  to  be  re- 
marked that  neither  Heidenhain  nor  Stiles  made  any  attempt 
to  dispute  the  truth  of  the  theory.  With  regard  to  dissemination 
generally,  attention  remained  focused  upon  the  route  which 
leads  by  way  of  the  trunk  lymphatics  to  the  axillary  and  supra- 
clavicular glands,  and  so  to  the  blood  stream. 

It  was  noticed  by  Handley,^  in  a  post-mortem  examination 
which  he  happened  to  attend  in  1909,  that  the  abdomen  was  full 
of  secondary  deposits,  while  the  chest  was  entirely  free.  In- 
vestigating the  subject  in  post-mortem  records,  he  found  this 
not  infrequently  the  case,  a  fact  which  appeared  to  him  incon- 
sistent with  the  usually  accepted  embolic  theory.  He  carried 
out  a  careful  investigation  of  the  tissues  in  the  epigastric  angle, 
in  cases  of  this  kind,  and  found  that  the  disease  was  obtaining 
direct  access  to  the  abdomen  through  the  linea  alba  just  below 
the  ensiform  cartilage.  He  then  cut  a  longitudinal  section  of 
the  tissues  of  the  abdominal  wall  down,  as  far  as  the  umbilicus, 
and  found  that  for  some  distance  below  the  ensiform  cartilage 
the  lymphatics  on  the  interior  surface  of  the  rectus  sheath  were 
choked  up  with  cancer  cells  for  some  little  distance,  while 
lower  down  the  tissues  were  free  from  growth.  It  seemed, 
therefore,  that  the  disease  was  spreading  in  a  centrifugal  man- 
ner away  from  its  point  of  origin  by  growing  along  the  lym- 
phatics much  as  a  ringworm  or  a  tertiary  syphilid  spreads. 

He  tested  this  hypothesis  in  other  cases  by  cutting  sections 
of  the  parietal  tissues,  many  inches  long,  radiating  in  various 
directions  from  the  primary  tumor,  and  thus  demonstrated  the 
occurrence  of  what  he  called  "the  microscopic  growing  edge 
of  permeated  lymphatics,"  a  zone  of  permeated  lymphatics  a 
few  millimeters  wide  forming  a  ring  of  larger  diameter  in  the 

1  Depage. — II  Congr^s  de  la  Societe  Internationale  de  Chir.,  Brussels, 
1908. 

'  Handley,  W.  Sampson. — ' '  Epigastric  Invasion  of  the  Abdomen  in 
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SPECIAL  TECHNIC  861 

apparently  healthy  tissues  of  the  deep  fascia,  and  remaining 
centered  upon  the  point  at  which  the  primary  growth  originated. 
The  difficulty  remained  that  at  points  inside  this  ring,  between 
it  and  the  massive  primary  growth,  no  permeated  lymphatics 
could  be  found,  although  scattered  naked-eye  nodules  were  pres- 
ent. Handley  inferred  that  the  permeated  lymphatics,  after  a 
time,  underwent  destruction,  and  he  was  able  to  trace,  micro- 
scopically, every  stage  of  the  process  by  which  this  was  accom- 
plished, thus  for  the  first  time  demonstrating  the  occurrence  in 
cancer  of  normal  curative  processes.  (Plate  XXXVIII.)  In 
connection  with  the  microscopic  growing  edge  he  made  a  further 
observation  that  the  normal  cell  excites  no  inflammatory  reac- 
tion in  the  tissues,  and  that,  as  he  expressed  it,  it  is  accepted  by 
the  tissues  as  a  normal  denizen  of  the  body.  Continuing  his 
studies  further,  he  showed  that  invasion  by  cancer  of  the  inter- 
nal organs  of  the  body  is  very  frequently  brought  about  by  the 
penetration  of  the  cancer  cells  to  the  serous  cavities,  and  their 
dissemination  from  these  cavities  by  gravity  and  by  visceral 
movements. 

The  application  of  microscopic  methods  on  a  macroscopic 
scale,  as  employed  by  Handley,  cannot  be  made  by  a  single  ob- 
server to  a  large  number  of  cases,  since  the  investigation  of 
one  case  occupies  weeks  or  months. 

In  order  to  generalize  the  conclusions  arrived  at,  Handley 
studied  the  post-mortem  records  of  a  large  number  of  cases. 
From  an  analysis  of  these  records  he  was  able  to  show  that  the 
distribution  of  the  metastases  was  inconsistent  with  the  embolic 
theory,  while  it  was  exactly  such  as  would  be  required  by  the 
permeation  theory. 

It  is  impossible  to  summarize  his  argument  in  a  brief  space, 

'  "t  as  an  example  it  might  be  cited  that  neither  subcutaneous 

^dules  nor  bone  deposits  are  found  distal  to  the  knee  or  to  the 

elbow,  that  subcutaneous  nodules  commence  close, to  the  primary 

j,,rovsi;h  and  spread  from  it  in  a  continuously  larger  circle  which 

ly  involve  the  upper  arms  and  the  root  of  the  thighs,  and 

at,  broadly  speaking,  the  nearer  a  bone  is  situated  to  the  seat 

the  primary  disease,  the  more  likely  is  it  to  show  secondary 

posits. 

It  may  also  be  noted  that,  as  might  be  expected  on  the  per- 
.  .eation  theory  basis,  pleural  adhesion  delays  the  course  of 
'1  oracic  dissemination,  a  fact  which  is  inexplicable  on  the 
rnbolic  hypothesis. 

Charles  H.  Mayo  has  stated  that  "The  more  recent  iijvesti- 

itions,  particularly  those  of  Handley  of  the  Middlesex  Hos- 
pital,   have    served    to    accentuate    and    extend    Heidenhain's 


362  THE   CANCER  PROBLEM 

views."  It  might  be  more  accurate  to  say  that,  while  Heiden- 
hain  and  Stiles  first  detected  the  growth  of  cancer  along  lym- 
phatic vessels  (a  process  named  by  Handley  "permeation"), 
they  formed  no  general  conception  of  the  process  of  dissemina- 
tion other  than  that  of  the  current  embolic  theory.  By  con- 
ceiving the  permeation  theory  of  dissemination,  and  establish- 
ing its  general  laws  upon  a  firm  basis  of  observation,  Handley 
seems  to  have  placed  the  entire  surgical  treatment  of  cancer 
upon  a  more  scientific  foundation. 

MODIFIED  OPERATION  FOR  CANCER  OF  THE  BREAST 

In  1912  Handley  ^  made  the  following  statement  with  refer- 
ence to  the  technic  modified  in  accordance  with  the  permeation 
theory : 

"It  is  yet  too  early  to  estimate  the  practical  benefits  of  the 
modified  operation  based  upon  the  permeation  theory,  which  I 
have  practiced  during  the  past  five  years.  I  am,  however,  able 
to  state  that  it  reduces  local  recurrence  in  the  skin  and  subcu- 
taneous tissues  to  a  very  low  percentage.  When  recurrence 
does  take  place,  it  usually  happens  (a)  in  the  anterior  medias- 
tinal glands,  appearing  deeply  at  the  anterior  ends  of  the  upper 
intercostal  spaces,  or  (&)  in  the  supraclavicular  glands,  or  (c) 
in  the  internal  organs.  In  all  these  situations  it  is  fair  to 
assume  that  cancer  cells  were  present  at  the  time  of  the  original 
operation.  My  experience  indicates  the  necessity  of  removing 
the  supraclavicular  glands  whether  they  are  enlarged  or  not, 
and  of  giving  a  prophylactic  course  of  X-rays  after  the  opera- 
tion." 

In  some  cases  there  is  su^h  profound  shock  in  breast  ampu- 
tations that  it  becomes  necessary  to  curtail  the  operative  pro- 
cedure, omitting  that  which  is  least  essential. 

In  the  view  that  removal  of  the  rectus  sheath  is  very  impor- 
tant, I  agree  with  Rodman,^  especially  where  dissemination  is 
extensive  or  where  the  disease  is  in  the  lower  part  of  the  breast. 
It  is  especially  important  in  the  right  side,  where  there  are 
avenues  of  extension  into  the  abdomen  along  the  falciform 
ligament. 

If  the  glands  are  extensively  involved  in  the  supraclavicular 
region,  extension  has  very  probably  taken  place  in  the  thorax, 
and  a  permanent  cure  cannot  be  expected.  It  must  be  borne  in 
mind,  however,  that  so  far  as  pressure  symptoms  are  concerned 

1  Handley. — Op.  cit.     ' '  Recent  Advances  in  the  Surgical  Treatment  of  Some 
Forms  of  Cancer,"   The  Universal  Medical  Record,  1912,  V,  pp.  385-406. 

2  Eodman. — See   General  Bibliography. 


SPECIAL   TECHNIC  363 

internal  cancer  is  far  less  distressing  than  is  external  cancer, 
and  removal  of  the  mass  in  the  neck  will  give  great  relief. 

The  method  I  now  employ  is  that  of  Rodman,  based  upon  the 
principles  of  the  Halsted  operation  with  Ilandley's  modifica- 
tions, according  to  the  permeation  theory.  In  typical  cases  the 
skin  incision  extends  to  the  anterior  fold  of  the  axilla,  and  is  so 
arranged  as  not  to  enter  the  axilla.  The  skin  flaps  are  thrown 
back,  the  costal  portion  of  the  pectoralis  major  is  severed  near 
the  humerus.  The  cut  end  is  sewed  with  small  catgut  to  prevent 
oozing.  The  muscles  are  then  laid  back  upon  the  chest  and  the 
highest  glands  are  dissected  away  from  the  structures  above. 
The  pectoralis  minor,  which  is  rarely  diseased,  is  denuded  of 
all  fascia.  If  not  diseased  a  small  strip  of  the  pectoralis  major 
may  be  advantageously  left.  If  any  of  the  muscle  tissue  is 
diseased,  or  its  covering  is  adherent  to  the  growth,  the  entire 
muscle  must  be  removed.  The  structures  are  dissected  from 
the  body  toward  the  breast.  After  all  the  fascia  is  separated 
above,  I  go  down  below  and  dissect  a  flap  on  the  abdomen,  in 
order  to  close  off  that  line  of  extension.  This  flap  of  connective 
tissue  and  fat  is  thrown  up  toward  the  breast  with  the  anterior 
layer  of  the  rectus  sheath  on  the  same  side.  If  the  disease  is 
low  down,  I  frequently  extend  the  dissection  to  the  other  side, 
carefully  taking  away  connective  tissue  and  fascia  lying  be- 
tween the  two  recti  muscles  high  up  near  the  ensiform  cartilage. 
The  next  incision  is  made  around  the  breast,  and  the  skin 
thrown  back  until  it  reaches  over  to  the  opposite  side,  and  well 
to  the  posterior  axillary  line.  The  muscle,  fascia,  fat,  and  that 
portion  of  skin  over  the  breast  with  the  mamma,  is  cut  away 
en  masse.  The  large  vessels  entering  the  mediastinum  are 
carefully  drawn  out,  cut  short,  and  clamped. 

Care  is  always  taken  to  avoid  undue  manipulation  of  the 
breast,  in  order  to  obviate  the  danger  of  extension. 

If  the  hemostasis  is  thorough  the  wound  may  be  closed  with- 
out drainage,  as  recommended  by  Rodman.  A  small  rubber 
tissue  drain  may  be  inserted  for  a  day  or  two. 

Usually  there  is  enough  skin  to  cover  the  area  without  graft- 
ing. It  is  easy  to  bring  the  skin  over  because  the  flaps  are  laid 
back  so  far  in  order  to  remove  the  fascia. 

By  employing  the  Rodman  incision,  with  the  general  prin- 
ciples of  Halsted,  and  recommendations  of  ITandley,  much 
better  results  should  be  obtained  than  heretofore. 

My  experience  has  been  at  variance  with  the  recent  state- 
ment of  Murphy,^  of  Chicago,  to  the  effect  that  he  had  never 

1  Murphy,  J.  B. — Clinical  Congress  of  Surgeons  of  North  America, 
1913. 


364,  THE   CANCER   PROBLEM 

seen  a  recurrence  in  the  clavicular  portion  of  the  pectoralis 
major  or  minor.  However,  it  seems  wise  and  safe  to  leave  the 
pectoralis  minor,  and  in  some  cases  the  clavicular  portion  of 
the  pectoralis  major,  thus  protecting  the  essential  structure  from 
pressure  by  skin  and  scar  tissue  in  the  axilla  as  Murphy  has 
urged. 

PERMEATION   THEORY   APPLICABLE    TO    OTHER    LOCALITIES 

According  to  Handley,  the  permeation  theory  of  the  spread 
of  cancer  probably  applies  to  every  form  of  carcinoma,  and 
the  technic  of  the  surgical  treatment  of  the  disease  in  other 
localities  is  as  much  amenable  to  adaptation  in  accordance  with 
this  theory  as  it  is  in  the  management  of  cancer  of  the  breast. 
He  has  demonstrated  permeation  in  carcinoma  of  the  stomach 
and  rectmn,  and  Lenthal  Cheatle  has  observed  it  in  cancer  of 
the  tongue. 

At  the  time  that  Handley  was  working  out  the  permeation 
theory  with  reference  to  the  breast,  I  made  it  a  practice,  not 
only  to  take  away  all  the  glands,  but  the  fascial  planes  and  all 
connective  tissue  around  the  vessels  and  muscles  in  juxtaposi- 
tion to  the  cancer.  A  case  in  point, ^  first  reported  in  1905,  was 
one  of  extensive  carcinoma  of  the  tongue  and  neck.  The  opera- 
tion was  performed  in  two  stages.  On  the  first  occasion  (March 
11,  1904)  the  submaxillary  and  sublingual  glands  on  either 
side  were  removed  and  the  salivary  ducts  were  extirpated  clear 
into  the  mouth.  Many  cancerous  glands  were  removed  from 
the  region  of  the  tonsil  on  the  left  side  to  the  dome  of  the 
pleura,  and  on  the  right  side  from  the  tonsil  to  the  division  of 
the  carotid  artery.  The  mouth  was  then  forced  open  and  part 
of  the  large  cauliflower  mass  on  the  tongue  cut  down  with 
Paquelin  cautery.  The  cauterized  surface  was  coated  daily 
with  Whitehead's  shellac.  Seventeen  days  later  a  second  op- 
eration was  performed,  when  the  left  corner  of  the  mouth  was 
incised  as  far  back  as  the  edge  of  the  masseter  muscle,  the 
tongue  was  drawn  out  and  completely  removed  by  an  elliptical 
incision  on  the  floor  of  the  mouth  encircling  the  tongue  in  front 
on  each  side.  A  flap  of  mucous  membrane  and  muscle  from 
the  right  glosso-epiglottic  fold  was  used  in  making  a  bridge  of 
tissue  across  the  fauces  in  front  of  the  epiglottis.  The  wound 
in  the  floor  of  the  mouth  was  closed  by  chromicized  catgut  and 

1  Bainbridge,  William  Seaman. — ' '  A  Case  of  Extensive  Carcinoma  of 
Tongue  and  Neck,  Presenting  Points  of  Special  Interest,"  American  Med- 
icine, March  25,  1905,  Vol.  IX,  No.  12,  pp.  477-478. 


SPECIAL  TECHNIC  365 

covered  with  shellac.  The  wound  in  the  cheek  was  closed  in 
the  usual  way  and  shellac  applied.  For  ten  years  the  patient 
lived  a  useful  life,  succumbing,  at  the  end  of  that  time,  to 
pneumonia.  At  the  time  of  his  death  cancer  had  developed 
along  the  alveolar  border  of  the  lower  jaw,  where  he  had  a  de- 
cayed tooth,  and  in  the  scar  in  the  floor  of  the  mouth.  There 
was  no  recurrence  in  the  neck. 

Since  this  experience  I  have  noticed  that  recurrence  is  less 
frequent  when  a  large  amount  of  fascia  is  removed.  For  a 
number  of  years  I  have  emphasized  the  importance  of  remov- 
ing far  more  fascia  than  skin.  This  has  been  impressed  upon 
my  mind  many  times  by  having  observed  small  palpable 
nodules  of  recurrent  cancer  under  the  skin. 

"OPERABILITY"    OF    CANCEB,    OF    RECTUM    EXTENDED    BY 
PERMEATION  THEORY 

Miles, ^  of  Edinburgh,  calls  attention  to  the  wide  difference 
of  opinion  with  reference  to  the  operability  of  cancer  of  the 
rectum,  giving  the  following  percentages:  Boas,  19  per  cent.; 
Witzel,  25  per  cent. ;  Czerny,  71  per  cent. ;  Bergman,  80  per 
cent. ;  Elsberg,  65  per  cent.,  Harrison  Cripps,  25  per  cent. 
According  to  his  own  experience,  75  per  cent,  of  cases  are  oper- 
able if  the  radical  abdomino-perineal  operation  is  employed. 
If  excision  by  the  perineal  methods  is  resorted  to,  over  90  per 
cent,  will  recur,  and  these  cases  he  considers  inoperable. 

Miles  cites  three  cases  which,  to  his  mind,  prove  conclusively 
that  the  operability  of  cancer  of  the  rectum  depends,  or  should 
depend,  not,  as  held  by  many,  upon  the  limited  extent  and 
mobility  of  the  growth,  "but  rather  upon  the  absence  of  visible 
permeation  or  metastatic  deposits  in  the  tissues  comprising 
the  zone  of  upward  spread,  a  condition  which  can  only  be  de- 
termined by  abdominal  exploration." 

The  radical  abdomino-perineal  operation  which  Miles  ^  em- 
ploys has  given  in  his  experience  the  following  results : 

Of  42  cases  operated  upon — 22  males  and  20  females — 17 
died  from  the  operation  (40  per  cent,  mortality).  Of  the  25 
who  survived  the  operation,  4  suffered  from  recurrence.  Of 
the  remaining  21  cases,  one  died  of  pneumonia  a  year  after  the 
operation,  and  one  committed  suicide  three  years  after  opera- 
tion,  neither  presenting  evidence  of  recurrence.     Of  the   19 

^  Miles,  W.  Ernest. — ' '  The  Treatment  of  Carcinoma  of  the  Eeetum  and 
Pelvic  Colon,"  Glasgow  Med.  Jour.,  February,  1912,  Vol.  LXXVII,  n.s. 
77,  p.  81. 

2  Ibid.— Brit.  Med.   Jour.,  October   1,   1910. 


366  THE   CANCER   PROBLEM 

who  survived  and  were  alive  at  the  time  of  the  report,  9  had 
been  operated  upon  less  than  2  years,  and  were  not  taken  into 
account.  Of  the  other  10,  3  lived,  without  manifest  signs  of 
recurrence,  for  over  4  years ;  3  for  over  3  years ;  2  for  over 
2 I/O  years;  and  2  for  over  2  years. 

From  his  experience  he  draws  the  following  conclusions: 

'"1.  That  cancer  of  the  rectum  spreads  both  intra-murally 
and  extra-murally. 

''2.  That  the  extra-mural  spread  takes  place  in  three  dis- 
tinct zones. 

"3.  That  a  cancer  situated  in  the  lower  part  of  the  rectum 
may  give  rise  to  early  metastases  in  the  pelvic  mesocolon  and 
pelvic  peritoneum. 

"4.  That  a  growth  in  the  upper  part  of  the  rectum  or  in 
the  terminal  portion  of  the  pelvic  colon  may  give  rise  to  spread 
situated  in  the  peri-anal  skin  and  in  the  ischiorectal  fat. 

"5.  That  the  tissues  of  the  three  zones  of  spread  are  vul- 
nerable to  spread  wherever  the  primary  growth  may  be  situated 
in  the  rectum. 

"6.  That,  although  perineal  operations  can  eradicate  the 
tissues  comprising  the  zones  of  lateral  and  downward  spread, 
they  are  quite  inadequate  for  reaching  the  tissues  of  the  zone 
of  upward  spread. 

"7.  That  the  only  operative  procedure  which  completely 
eradicates  the  tissues  forming  the  three  zones  of  spread  is  the 
radical  abdomino-perineal." 

Others,  notably  Monsarrat  and  Williams,^  do  not  accept  the 
permeation  theory  concerning  the  dissemination  of  cancer  of 
the  rectum.  Handley's  theory  is  based  upon  the  finding,  six 
inches  or  more  above  the  primary  growth,  of  cancer  cells  con- 
taining mucin  or  small  particles  of  mucus,  thought  by  him  to 
be  degenerated  cancer  cells.  The  finding  of  these  mucin-con- 
taining  cells  in  the  plane  of  tissue  lying  between  the  blind  ends 
of  Lieberkiihn's  follicles  and  the  underlying  muscularis  mu- 
cosae was  considered  by  him  as  proof  of  the  permeation,  by  the 
cancer,  of  the  lymphatics  in  this  neighborhood. 

Monsarrat  and  Williams,  on  the  other  hand,  are  inclined  to 
the  belief  that  the  presence  of  mucin  indicates  the  retention  by 
the  cancer  cells  of  their  normal  ability  to  secrete  mucin,  rather 
than  that  the  mucin  is  a  degeneration  product  of  cancer. 

'Monsarrat,  K.  W.,  and  Williams,  Idwal  J. — Brit.  Jour.  Surg.,  1913,  I, 
173. 


SPECIAL  TECHNIC  367 


PERMEATION   THEORY   APPLICABLE   TO    MELANOTIC    SARCOMA 

In  the  case  of  melanotic  sarcoma,  Handley  claims  to  have 
obtained  strong  microscopic  evidence  that  the  process  of  dis- 
semination is  primarily  one  of  centrifugal  lymphatic  permea- 
tion, which,  in  the  later  stages  of  the  disease,  is  changed  into 
blood  dissemination. 

If  the  operation  for  melanotic  sarcoma  is  rightly  planned, 
Handley  maintains  that  the  prospects  should  not  be  so  hopeless 
as  is  generally  assumed. 

The  principles  upon  which  excision  should  be  carried  out  are 
stated  by  him  as  follows :  "A  circular  incision  should  be  made 
through  the  skin  around  the  tumor  at  what  is  judged  by  present 
standards  to  be  a  safe  and  practicable  distance.  The  incision, 
situated  as  a  rule  an  inch  from  the  edge  of  the  tumor,  should 
be  just  deep  enough  to  expose  the  subcutaneous  fat.  If  neces- 
sary, two  radial  lineal  incisions  extending  from  the  circular 
incision  should  be  made  on  opposite  sides  of  the  tumor  so  as  to 
facilitate  the  elevation  of  the  skin  flaps,  which  forms  the  next 
step.  The  skin,  with  a  thin  attached  layer  of  subcutaneous  fat, 
is  now  to  be  separated  from  the  deeper  structures  for  about 
two  inches  in  all  directions  round  the  skin  incision.  At  the  ex- 
treme base  of  the  elevated  skin  flaps  a  ring  incision  down  to 
the  muscles  surrounds  and  isolates  the  area  of  deep  fascia  and 
overlying  deeper  subcutaneous  fat  to  be  removed.  The  fascial 
area  is  next  to  be  dissected  centripetally  from  the  muscles 
beneath  to  a  line  which  corresponds  with  that  of  the  circular 
skin  incision.  Finally,  the  whole  mass  with  the  growth  at  its 
center  is  removed  by  scooping  out  with  a  knife  a  circular  area 
of  the  muscle  immediately  subjacent  to  the  growth.  The  edges 
of  the  wound  are  to  be  brought  together  as  convenience  dic- 
tates." 

Having  demonstrated  that  permeation  of  the  lymphatic 
plexus  of  the  deep  fascia  soon  takes  place  around  injected 
glands,  just  as  it  does  around  the  primary  growth,  Handley  ^ 
insists  that  excision  of  the  glands  must  be  carried  out  on  exactly 
the  same  principles  as  excision  of  the  primary  growth.  He 
considers  it  of  the  greatest  importance  to  remove  the  apparently 
healthy  set  of  glands  above  the  obviously  enlarged  ones. 

1  Handley,  W.  Sampson. — Op.  cit.  ' '  Eecent  Advances  in  the  Surgical 
Treatment  of  Some  Forms  of  Cancer,"  The  Universal  Medical  Becord, 
1912,   V,  pp.   385-406.     See  also: 

Eve,  Sir  Frederic. — "A  Lecture  on  Melanoma,"  The  Practitioner,  Feb 
ruary,   1903. 

Acton,  H.  W. — The  Middlesex  Hospital  Journal,  1905. 


368  THE   CANCER   PROBLEM 

From  his  confessedly  limited  experience  with  his  operative 
procedure  in  cases  of  melanotic  sarcoma,  Handley  concludes 
that  this  disease  may  be  removed  from  the  category  of  prac- 
tically incurable  diseases,  and  transferred  to  that  of  affections 
such  as  cancer  of  the  breast  and  uterus,  "where  fear  is  more 
equally  counterpoised  by  hope." 

B.     PLASTIC    PROCEDURES 

When  the  physical  house — the  human  body — is  aflame  with 
the  "red  plague" — cancer — the  surgeon  is  called  to  extinguish 
the  flame — to  eradicate  the  disease — just  as  the  fireman  is 
summoned  to  check  the  fire  which  consumes  the  house  of  brick, 
mortar,  and  wood.  When  all  visible  evidence  of  the  bodily 
flame  is  destroyed,  the  surgeon  is  expected  to  utilize  his  skill  in 
repairing  the  damage  done  by  this  agent  or  by  himself  in  his 
efforts  to  master  it,  just  as  the  carpenter  or  the  builder  is  ex- 
pected to  repair  the  havoc  wrought  by  fire,  or  by  the  fireman's 
efforts  to  control  it.  The  fireman  seeks  to  leave  no  smoldering 
ember  hidden  by  wall,  floor  or  ceiling,  which  may  later  break 
into  a  flame  of  destruction.  So,  too,  the  surgeon  endeavors  to 
overlook  no  minute  point  of  danger  which  may  subsequently 
destroy  limb  or  life.  "The  minimum  of  destruction,  with  the 
maximum  of  safety,"  is  the  watchword  of  both. 

In  his  efforts  to  eradicate,  not  only  the  macroscopic,  but 
the  microscopic,  manifestations  of  cancer,  it  sometimes  be- 
comes necessary  for  the  surgeon  to  remove  considerable  areas 
of  tissue.  The  disease  may  thus  be  entirely  eliminated,  but 
at  the  sacrifice  of  extensive  and  disfiguring  tissue  defects.  In 
such  cases  plastic  surgery  may  be  called  into  requisition,  the 
procedure  varying,  of  course,  in  accordance  with  the  require- 
ments of  the  particular  part  involved. 

In  many  instances  the  defect  may  be  filled  in  with  skin- 
grafts,  taken  from  the  patient  or  from  another  subject,  with 
flaps  from  the  contiguous  territory  of  the  patient's  body,  or 
with  tissue  transplanted  from  another  part. 

It  is  possible,  for  example,  in  a  beginning  tumor  of  the 
breast,  to  save  skin  and  nipple,  and  to  fill  in  the  defect  made  by 
removal  of  the  glandular  tissue,  with  a  flap  of  fat  from  the 
patient's  back.  By  sliding  this  forward  underneath  the  skin, 
the  rotundity  of  the  breast  may  be  maintained  so  that  it  is 
almost  impossible  to  detect  the  slightest  deformity. 

In  cancer  of  the  nose,  by  rhinoplasty  a  nose  may  be  made 
with  a  flap  from  the  patient's  arm,  which  is  kept  in  position 


SPECIAL   TECHNIC  369 

over  the  head  until  union  has  taken  place  between  the  flap  and 
the  tissues  to  which  it  is  attached.  When  the  flap  is  severed 
from  the  arm,  by  shaping  the  nostrils,  a  fairly  good  nose  may 
be  made.  When  only  the  tip  is  involved  it  may  be  replaced 
to  advantage  by  using  the  end  of  the  finger.  When  the  septum 
or  the  nasal  bones  are  destroyed  in  removing  the  cancer  a  piece 
of  cartilage  from  a  rib  may  be  used  to  advantage. 

In  similar  manner,  by  means  of  ophthalmoplasty,  otoplasty, 
and  cheiloplasty,  defects  left  after  operation  for  cancer  of 
the  eye  and  orbit,  the  external  ear,  and  the  lips,  respec- 
tively, may  be  remedied  with  flaps  taken  from  other  parts  of 
the  body. 

Illustrative  cases  of  these  procedures  are  to  be  found  in 
many  text-books  and  other  contributions.  I  have  presented 
many  such  cases  from  time  to  time,^  and  need  not  repeat  them 
here. 

C.     PALLIATIVE    MEASURES 

In  cases  of  very  advanced  cancer,  operations  having  for  their 
purpose  the  palliation  of  symptoms  and  the  prolongation  of  life 
are  applicable  to  practically  every  part  of  the  body. 

NERVOUS    SYSTEM 

Neurectomy. — ^When  a  malignant  neoplasm  presses  upon 
nerves,  causing  the  most  excruciating  pain,  relief  may  be  ob- 
tained by  neurectomy.  As  a  rule  the  cutting  of  one  or  more 
nerves  directly  supplying  the  area  pressed  upon  will  suffice.  It 
has  been  suggested,^  however,  that  in  some  cases  division  of  the 
sensory  roots  of  the  spinal  nerves  is  justifiable. 

In  a  number  of  instances  of  cancer  of  the  floor  of  the  mouth 
I  have  cut  the  branches  of  the  inframaxillary  division  of  the 
fifth  nerve,  giving  great  relief. 

Decompressive  or  Decompression  Operations  are  employed  for 
irremovable  tumors  of  the  brain.  Vomiting,  headache,  choked 
disc,  and  other  distressing  symptoms  of  pressure  may  be  re- 
lieved by  removing  a  portion  of  the  skull  and  a  corresponding 
area  of  dura,  closing  the  soft  parts  over  the  defect. 

The  site  selected  for  decompression  should  be  over  as  unim- 
portant an  area  of  the  cortex  as  possible. 

The  technic  of  such  operations  has  been  variously  described 

1  Bainbridge,  William  Seaman. — See  General  Bibliography. 

2  Eowntree,  Cecil. — ' '  Tumors, "  in  "A  System  of  Treatment, ' '  edited 
by  A.  Latham  and  T.  Crisp  English,  Vol.  I,  p.  135. 


370  THE   CANCER   PROBLEM 

by  Macewen,  Horseley,  Gushing,  and  others.  For  a  full  list 
of  references  bearing  upon  the  subject  the  reader  is  referred 
to  the  general  bibliography. 

Perforation  of  the  corpus  callosum  has  been  suggested  and 
employed  by  Anton  and  v.  Bramman  in  cases  of  tumors  of  the 
brain  accompanied  by  internal  hydrocephalus  and  choked  disc 
with  threatened  blindness.  These  authors  also  advocate  punc- 
ture of  the  corpus  callosum  as  a  preliminary  procedure  when 
intracranial  pressure  is  sufficient  to  interfere  with  palpation  of 
the  brain  or  removal  of  the  tumor. 

LYMPHATIC    SYSTEM. 

Lymphangioplasty — Handlcy  ^  suggested  a  procedure,  to 
which  he  applied  the  term  "l^onphangioplasty,"  for  the  relief  of 
brawny  arm,  the  distressing  condition  which  is  said  to  compli- 
cate 16  per  cent,  of  cases  of  advanced  cancer  of  the  breast. 
This  painful  swelling  of  the  arm  is  accounted  for  by  Handley 
as  being  the  result  of  the  blocking  of  lymph  channels  by  the 
growth  itself,  or  by  the  perilymphatic  fibrosis  which,  according 
to  the  permeation  theory  of  dissemination,  accompanies  the 
extension  of  mammary  cancer. 

The  method  consists  in  providing  artificial  lymphatic  chan- 
nels in  the  subcutaneous  tissues  of  the  brawny  arm  by  the 
passage  of  long  strands  of  silk  from  the  wrist  to  the  healthy 
tissues  beyond  the  axilla. 

Lymphangioplasty  is  not  applicable  to  all  cases  of  brawny 
arm.  The  procedure  is  contraindicated  under  the  following 
circumstances : 

(1)  In  the  presence  of  pleural  effusion  on  the  affected  side. 

(2)  When  the  pain  is  largely  due  to  pressure  of  the  tumor 
upon  the  brachial  plexus. 

(3)  When  the  mammary  groAvth  is  so  extensive  that  a  suffi- 
cient area  of  non-ulcerated  skin  is  not  available  for  carrying 
the  threads. 

(4)  When  infection  of  the  silk  threads  is  inevitable  because 
of  the  generally  septic  condition. 

(5)  When  the  threads  have  to  pass  through  cancerous 
tissue. 

Handley  has  recently  made  the  following  statement  ^  con- 
cerning the  method : 

'  Handley,  W.  Sampson. — ' '  A  New  Method  for  the  Relief  of  the  Brawny 
Arm  of  Breast  Cancer  and  for  Similar  Conditions  of  Lymphatic  OEdema, " 
Lancet,  March  14,  1908,  p.  783:  also  Archives  of  the  Middlesex  Hosp., 
Vol.  12,  p.  28. 

2  Personal  communication,  December  2,  1913. 


SPECIAL  TECHNIC  371 

"There  is  undoubtedly  a  considerable  percentage  of  failures, 
and  since  I  have  not  been  able  to  find  out  how  to  distinguish 
cases  in  which  success  will  follow  and  those  in  which  the  opera- 
tion will  be  useless,  I  have  not  felt  able  to  press  the  operation 
on  patients  as  much  as  I  did  when  my  experience  was  smaller. 
I  would  now  oifer  it  to  patients  as  affording  a  good  chance  of 
relief,  but  would  avoid  anything  like  a  promise  of  relief. 

"I  accept  provisionally  Madden's  statements  that  the  silk 
becomes  blocked  by  fibrosis  around  it  within  a  relatively  short 
time.  If  this  is  so,  then  the  successful  cases  must  be  explained 
somewhat  as  follows:  That  the  temporary  drainage  supplied 
by  the  silk  restores  the  current  in  certain  lymphatic  channels 
of  the  limb  which  are  merely  temporarily  occluded  by  the  pres- 
sure of  the  oedema,  and  not  actually  fibrosed,  and  so  reestab- 
lishes the  disturbed  equilibrium. 

"Though  the  operation  has  not  fulfilled  all  my  hopes,  I  be- 
lieve it  will  have  a  place  in  surgery  until  some  better  substitute 
than  amputation  of  the  limb  is  available." 

I  have  employed  lymphangioplasty  in  six  cases  of  bravniy 
arm.  In  one  case  infection  took  place,  despite  the  best  of  care. 
In  two  cases  there  was  no  appreciable  benefit.  In  the  three 
remaining  cases  there  seemed  to  be  great  improvement  and 
marked  relief  for  a  number  of  months. 

The  principle  of  lymphangioplasty  has  been  applied  by 
Handley  and  others  to  the  continuous  subcutaneous  drainage  of 
the  abdomen  in  cases  of  ascites  resulting  from  advanced  cancer 
of  the  abdominal  organs. 

Paracentesis  abdominalis,  or  the  withdrawal  of  ascitic  fluid 
by  tapping,  should  be  resorted  to,  as  required,  in  all  cases  of 
hydroperitoneum  or  abdominal  dropsy.  This  condition  may 
accompany  any  form  of  malignant  neoplasm,  primary  or  sec- 
ondary, of  the  abdominal  organs.  It  is  particularly  notable  in 
the  rare  variety  known  as  malignant  papillomata.  The  fluid 
reaccumulates  very  rapidly,  necessitating  frequent  tappings. 
In  one  case,  cited  elsewhere  (Section  VII,  Chapter  III,  p.  214), 
the  patient  has  been  tapped  seventy-six  times. 

Thoracocentesis,  or  the  withdrawal  of  pleuritic  fluid  by  tap- 
ping, sometimes  affords  great  relief  in  advanced  cancer  of  the 
breast,  in  which  the  blocking  of  the  lymph  channels  extends  to 
the  thoracic  cavity,  and  in  extensive  cancer  of  the  lung  or 
mediastinum.  Repeated  tappings  are  necessary,  but,  when 
resorted  to,  life  may  be  prolonged  considerably,  and  the  patient 
rendered  much  more  comfortable. 


372  THE   CANCER   PROBLEM 

VASCULAR    SYSTEM 

"STARVATION    LIGATXTRE" 

HISTORY 

The  ligation  of  arteries  is  said  to  have  heen  practiced  at  least 
eighteen  hundred  years  before  Plarvey  discovered  the  circulation 
of  the  blood  (1616-1619).  It  is  not  known  who  first  employed 
the  method,  but  ligation  of  bleeding  vessels  for  the  control  of 
hemorrhage  is  mentioned  in  the  writings  of  Celsus  (30  B,  C. 
to  50  A.  D.),  and  of  Galen  (131-211  A.  D.).  Aetius  (502-575 
A.  D.),  Avicenna  (980-1037  A.  D.),  and  others  of  the  early 
authorities  on  surgery  employed  the  ligature  for  the  control 
of  hemorrhage  and  in  the  treatment  of  aneurysms. 

With  the  discovery  of  the  circulation,  and  the  development 
of  knowledge  concerning  the  part  played  by  the  blood  in 
the  nourishment  of  normal,  as  well  as  abnormal,  tissue,  the 
method  of  ligating  arteries  increased  in  scope.  It  then  came 
to  be  applied,  not  only  for  the  control  of  hemorrhage  occurring 
as  the  result  of  accident  or  surgical  procedure,  and  for  the 
treatment  of  aneurysm,  but  for  the  purpose  of  causing  atrophy 
of  organs  or  other  parts  of  the  body,  and  to  lessen  the  nutrition 
of  inoperable  new  growths,  thus  checking  their  further  develop- 
ment and  perhaps  causing  their  disappearance. 

The  last-named  use  of  the  ligature  has  given  rise  to  the  term 
"starvation  ligature."  The  procedure  has  been  applied  to  the 
uterus,  ovaries,  testes,  spleen,  thyroid  gland,  tongue,  and  other 
parts  of  the  body. 

The  discoverer  of  the  circulation  of  the  blood  is  himself 
credited  with  originating  this  newer  application  of  the  ligature 
in  surgery,  although  it  has  been  said  that  Johan  Muys,  in  1626, 
recommended  the  "starvation  method"  by  means  of  arterial 
ligatures,  basing  his  idea  upon  procedures  then  in  use  among 
veterinarians.  For  a  long  time  the  method  was  known  as  "Har- 
vey's method."  His  first  and,  so  far  as  is  known,  his  only 
application  of  the  procedure  was  made  in  1651,  when  he  is 
said  to  have  treated  successfully  a  case  of  elephantiasis  of  the 
scrotum  and  testicle  by  ligating  the  spermatic  artery. 

The  surgery  of  the  arteries,  particularly  the  "starvation 
ligature,"  remained  a  practically  neglected  field  for  many 
years.  The  next  recorded  application  of  this  procedure  was 
made  by  Lange  in  1707,  when  he  employed  it  in  the  treatment 
of  goiter. 

A  hundred  years  elapsed  before  the  method  was  again  em- 
ployed.    Travers,  in  1809  (or  1805,  according  to  Tuffier),  em- 


SPECIAL   TECHNIC  373 

ployed  it  in  the  treatment  of  a  tumor  of  the  orbit,  said  by  some 
writers  to  have  been  a  fungns  growth,  and  by  others  an  an- 
eurysm. He  tied  the  common  carotid  artery,  this  being  the 
first  recorded  instance  of  ligation  of  the  vessel  for  this  purpose. 

Dalrymple,  in  1813,  tied  the  same  vessel  in  the  treatment 
of  a  fungus  growth  of  the  orbit  (see  Mauclaire,^  1000,  p.  365.) 

Sir  Astley  Cooper,  in  1814,  tied  the  humeral  artery  in  an 
unsuccessful  attempt  to  starve  a  sarcoma  of  the  radius. 

In  1815  Maunoir  treated  a  sarcocele  of  the  testicle  by  tying 
the  spermatic  arteries. 

Cancer  of  the  tongue  was  treated  by  Mirault  (1833)  by  the 
ligation  of  the  lingual  artery,  and  similar  experiments  were 
made  by  Koux,  Demarquay,  Broca,  Magendie,  and  others. 

Bier,  in  1889,  tied  the  hypogastric  arteries  for  the  purpose 
of  causing  atrophy  of  the  prostate,  and  in  1893  the  same  au- 
thority treated  fibro-adenoma  of  the  breast  by  the  ligation  of 
the  mammary  arteries.  Simultaneous  ligation  of  both  internal 
iliac  arteries  for  prostatic  hypertrophy  was  practiced  by  Willy 
Meyer,  von  Bergmann,  Koenig,  and  others. 

In  1889  Wyman  treated  malarial  hypertrophy  of  the  spleen, 
and  in  1894  Tricomi  treated  enlargement  of  the  spleen  (leuke- 
mic splenomegaly)  by  ligating  the  splenic  artery. 

Sir  Frederic  Treves,  in  1892,  reported  a  case  of  sarcoma 
of  the  buttock  treated  by  ligation  through  a  median  incision 
of  the  internal  iliac  artery  of  the  affected  side.  The  tumor 
was  of  three  months'  duration,  and  was  not  amenable  to  ex- 
cision. Remarkable  shrinkage  of  the  growth  followed  the 
operation,  the  pain  was  greatly  diminished,  and  the  patient 
was  able  to  walk  for  ten  months.  He  died  fourteen  months 
after  the  operation.  In  reporting  this  case  Treves  emphasized 
his  belief  that  sarcoma  is  more  amenable  to  treatment  by 
this  method  than  is  carcinoma. 

In  1893  George  Wherry  reported,  in  the  London  Lancet,  "a 
successful  case  of  intraperitoneal  ligation  of  the  internal  iliac 
artery."  The  method  was  applied  in  this  instance  to  a  large 
pulsating  tumor  upon  the  upper  posterior  and  outer  part  of  the 
left  innominate  bone,  of  nine  months'  duration.  The  tumor 
shrank,  the  pain  became  much  less,  and  the  pulsation  ceased. 

In  an  article  on  the  ligation  of  arteries  in  cases  of  malignant 
disease,  published  in  1895,  John  H.  Packard,  of  Philadelphia, 
reported,  among  others,  a  case  of  pulsating  tumor  of  the  upper 
part  of  the  left  femur,  treated  by  means  of  ligation  of  the  in- 
ternal iliac  artery  of  the  affected  side.  The  throbbing  and  pain 
ceased,  some  motion  returned  to  the  hip-joint,  which  had  been 
1  Mauelaire. — See  General  Bibliography. 


374  THE   CANCER   PROBLEM 

fcxed  in  partial  flexion  bj  the  mass  of  the  tumor,  the  growth 
diminished  in  size,  and,  after  nearly  six  months  in  the  hospital, 
the  patient,  able  to  walk  about  on  crutches,  was  discharged. 

The  application  of  the  "starvation  ligature"  to  tumors  of  the 
carotid  and  pelvic  regions  is  given  below,  under  separate 
headings. 

LIGATION  AND  EXSECTION  OF   THE  EXTERNAL   CAROTID  ARTERY 
(DAWBARN  METHOD)    IN  THE   TREATMENT  OF  MALIG- 
NANT   TUMORS    OF    HEAD    AND    FACE 

The  literature  of  the  general  subject  of  ligation  of  the  carotid 
arteries  is  voluminous,  and  it  is  not  my  purpose  to  review  it 
here.  For  those  who  are  particularly  interested  ample  refer- 
ences are  given  in  the  General  Bibliography. 

The  literature  of  the  ^'starvation  ligature"  as  applied  to  these 
vessels  is  meager  and  chaotic.  Neither  in  the  earlier  days  of 
its  use  nor  in  later  times  has  the  method  received  the  attention 
it  would  seem  to  merit. 

In  his  masterful  essay :  "Surgical  Anatomy  and  History 
of  the  Common,  External,  and  Internal  Carotid  Arteries," 
Dr.  John  A.  Wyeth,  of  New  York,  analyzes  789  cases  of  liga- 
ture of  the  common  carotid,  of  which  87  were  for  malignant 
tumors  other  than  those  of  the  orbit,  and  8  for  malignant  vascu- 
lar tumors  of  the  orbit.  He  also  analyzed  18  cases  of  ligation 
of  the  internal  carotid,  and  91  of  the  external  carotid.  Of  67 
cases  of  ligature  of  the  external  carotid  alone,  15  were  tied  ''to 
relieve  or  cure  so-called  malignant  growths."  Of  the  18  cases 
in  which  the  internal  carotid  was  tied,  in  only  one  case  was  the 
artery  alone  ligated,  and,  according  to  Wyeth,  "nothing  reliable 
as  to  the  practicability  of  this  operation  can  be  deduced."  This 
one  case  was  not  one  of  the  "starvation  treatment,"  and  we  have 
no  statistics  upon  the  "starvation  ligature"  as  applied  to  the  in- 
ternal carotid  alone. 

The  case  of  Travers,  mentioned  above,  re-awakened  interest 
in  this  procedure  as  applied  to  the  common  carotid.  The  idea 
was  gradually  extended,  a  number  of  cases  of  the  successful 
treatment  of  malignant  tumors  of  the  head  and  face  being  re- 
ported by  this  method. 

Pilz,  in  1868,  published  all  the  cases  of  ligation  of  the  com- 
mon carotid;  Madelung,  in  1874,  published  all  cases  of  ligation 
of  the  internal  carotid,  and  Wyeth,  in  1878,  brought  these 
tables  up  to  date,  with  the  addition  of  a  number  of  cases  re 
ported  to  him  by  correspondence.  Lipps,  in  1893,  brought 
Madeluno-'s  table  to  date. 


SPECIAL   TECHNIC  875 

The  first  application  of  a  ligature  to  the  external  carotid 
artery  in  the  treatment  of  a  tumor  of  any  sort,  according  to 
Madelung  and  Lipps,  appears  to  have  been  made  about  1830. 
It  was  not  until  1854  or  1855  that  bilateral  and  unilateral  liga- 
tion of  this  artery  for  malignant  growths  of  the  buccal  cavity, 
tongue,  and  pharynx  was  employed  in  seven  cases  without  suc- 
cess by  Maisonneuve.  These  were  reported  for  the  first  time  by 
Guyon,  in  1868. 

The  editor  of  ''Schmidt's  Jahrbucher,"  in  1875,  cites  the 
next  reported  case,  in  which  Lannelongue,  in  1873,  is  supposed 
to  have  ligated  one  or  both  (it  is  not  stated  whether  the  ligation 
was  bilateral  or  unilateral)  external  carotid  arteries  for  in- 
operable sarcoma  of  the  tongue  and  face. 

The  results  in  all  these  cases  are  given  in  the  tabulated 
records  contained  in  Wyeth's  essay,  mentioned  above,  to  which 
the  reader  is  referred  for  more  detailed  information. 

The  next  record  of  this  procedure  is  found  in  the  Medical 
News,  1887,  where,  among  nineteen  others  mentioned.  Dr.  J.  D. 
Bryant,  of  New  York,  reports  two  cases  in  his  own  practice. 

Another  decade  passed  before  the  "starvation  ligature,"  as 
applied  to  the  external  carotid  arteries,  is  recorded  again. 
Tuf&er,  in  a  paper  read  before  the  French  Surgical  Associa- 
tion in  1897,  cited  vaguely  three  cases  in  which  he  tied  the 
external  carotid.  He  also  summarizes  the  history  of  the  pro- 
cedure. 

In  1900  Mauclaire  reviewed  briefly  the  history  of  "ligatures 
atrophiantes." 

It  was  not,  however,  until  the  appearance  of  the  Samuel  D. 
Gross  Prize  Essay,  "The  Treatment  of  Certain  Malignant 
Growths  by  Excision  of  the  External  Carotids,"  by  Robert  H. 
M.  Dawbarn,  that  the  "starvation  ligature"  became  the  modi- 
fied "starvation  treatment"  which  is  now  an  established  pro- 
cedure in  the  treatment  of  advanced  cancer  of  the  mouth  and 
face. 

In  this  work  Dawbarn  says,  with  reference  to  simple  liga- 
tion: "In  some  instances  formidable  and  rapidly  growing 
tumors  have  disappeared  after  ligation  of  the  nutrient  vessels, 
although  there  must  always  be  some  doubt,  so  incomplete  are 
the  records  of  these,  as  to  the  accuracy  of  the  diagnosis  of 
malignancy.  It  appears  probably  the  fact  that  undoubted  ma- 
lignancy— as  shown  by  glandular  implication,  cachexia,  micro- 
scopical examination,  etc. — has  never  been  permanently 
arrested  by  ligature."  Of  the  thirteen  cases  of  ligation  of  the 
external  carotid  reported  by  others  and  tabulated  by  Dawbarn, 
not  one,  he  says,   was  attended  by  a  permanently  favorable 


376  THE   CANCER   PROBLEM 

result,  although  it  must  be  remembered  that  most  of  them  were 
desperate  eases,  and  that  ligature  was  practiced  as  a  forlorn 
hope  rather  than  as  the  operation  of  choice. 

Realizing  that  the  results  of  this  procedure  were  unsatisfac- 
tory because  of  the  rapid  resumption,  by  anastomosis,  of  free 
arterial  circiilation,  Dawbarn  sought  to  modify  the  method  by 
effecting  the  starvation  of  the  growth  by  means  of  carotid 
excision. 

Since  the  publication  of  Dawbarn's  essay  many  operators 
have  followed  his  method,  with  varying  degrees  of  success,  some 
verifying  the  observations  of  the  essayist. 

The  technic  which  I  employ  as  to  ligation,  excision,  and  in- 
jection is  essentially  that  described  by  Dawbarn,  only  such 
modifications  being  made  as  the  exigencies  of  the  individual 
case  require. 

TECHNIC    OF    CAROTID    EXCISION    AND    INJECTION    OF    THE    TWO 
TERMINAL  BRANCHES 

The  patient  is  placed  upon  the  operating  table  with  the  head 
well  extended,  the  face  held  averted  to  the  opposite  side,  and 
the  shoulders  raised  by  means  of  a  pad  or  block. 

The  incision  extends  from  near  the  level  of  the  tip  of  the  ear 
downward,  close  behind  the  angle  of  the  jaw,  to  the  level  of  the 
middle  of  the  larynx,  the  greater  cornu  of  the  hyoid  bone  being 
considered  the  median  point.  This  brings  the  ends  of  the  in- 
cision over  the  artery,  but  between  these  points  the  cut  curves 
inward,  with  the  convexity  toward  the  median  line  of  the  neck. 
The  mid-point  of  the  curve  is  thus  brought  1^/2  centimeters 
nearer  the  median  line  than  ordinarily  advised,  and  gives  a 
gain  in  speed  and  safety. 

The  incision  made,  the  work  proceeds  from  its  lower  toward 
its  upper  extremity. 

The  superior  thyroid,  as  a  rule,  is  the  first  branch  of  the 
external  carotid  to  be  exposed.  It  is  easily  recognized  by  its 
definitely  downward  course  throughout.  Tracing  this  back  to 
its  origin,  the  external  carotid  is  reached,  and  a  provisional 
ligature,  to  be  used  for  quick  control  of  hemorrhage  in  case  of 
need,  is  placed  around  the  vessel.  The  ligature,  of  chromicized 
catgut,  is  not  tightened  until  later. 

The  superior  thjToid  is  now  tied  in  two  places  with  chromi- 
cized catgut,  and  divided  between  the  ligatures. 

Each  branch  in  turn,  except  the  two  terminals  and,  on  oc- 
casion, the  occipital,  is  treated  in  like  manner,  the  ligation  and 
division  in  each  case  being  as  far  as  practicable  from  the  parent 


SPECIAL   TECHNIC  377 

vessel,  the  object  being  to  sacrifice  as  much  as  possible  of  the 
branch  and  its  own  unnamed  branches.  Sometimes,  as  in  the 
case  of  the  lingual,  a  sub-branch,  as  the  dorsalis  linguoe,  may 
be  individually  ligated. 

When  all  the  branches  except  those  mentioned  have  been 
ligated  and  divided,  the  external  carotid  itself  is  tied  in  two 
places  and  divided  between  the  ligatures. 

The  distal  end  of  the  external  carotid  is  now  seized  and  car- 
ried underneath  the  transverse  loop  of  the  twelfth  nerve,  and 
again  beneath  the  conjoined  stylohyoid  and  posterior  belly  of 
the  digastric,  coming  to  the  surface  at  a  level  above  these  two 
muscles. 

When  it  is  possible,  the  artery  is  followed  up  to  its  bifurca- 
tion and  a  ligature  is  placed  around  the  apex  of  the  V  made  by 
its  terminal  branches. 

Especial  care  must  be  exercised  here  not  to  injure  the  lower 
branches  of  the  pes  anserinus  and  thus  cause  facial  paralysis, 
nor  to  cut  through  some  of  the  smaller  ducts  of  the  parotid 
gland,  thus  causing  a  salivary  fistula.  General  care  must  be 
exercised  to  avoid  the  various  nerves  and  vessels  in  the  con- 
tiguous tissues.  It  goes  without  saying  that  the  tissues  through- 
out the  operation  should  be  handled  very  gently. 

I  prefer  the  special  Dawbarn  artery  clamp  to  the  blunt 
aneurysm  needle  for  passing  the  ligatures. 

With  all  other  branches  ligated  and  divided,  and  the  main 
trunk  treated  in  like  manner,  the  operator  next  proceeds  to 
inject  the  two  terminal  branches,  the  superficial  temporal  and 
the  internal  maxillary. 

For  this  purpose  the  following  special  instruments,  in  addi- 
tion to  the  equipment  for  ordinary  surgical  work,  are  required : 
(1)  A  metal  or  glass  syringe  that  permits  of  sterilization,  with 
a  capacity  of  about  10  c.  c.  The  nozzle  should  be  sufiiciently 
slender  to  readily  enter  the  rubber  tubing  by  means  of  which 
the  syringe  is  attached  to  the  cannula.  (2)  A  glass  cannula, 
4-5  cm.  in  length,  with  a  caliber  of  about  that  of  an  ordinary 
steel  knitting  needle.  One  end  is  beveled,  the  other  grooved 
transversely  for  holdiing  the  thread  by  means  of  which  the  can- 
nula is  attached  to  the  rubber  tubing  above  mentioned.  (3)  A 
piece  of  rubber  tubing  2-3  cm.  in  length.  A  short  piece  of  soft- 
rubber  catheter  may  be  used  for  this  purpose.  (4)  One  pair 
of  scissors,  small,  sharp-pointed,  and  straight.  (5)  One  tenac- 
ulum, smallest  size,  single  hook.  (6)  Glass  pipette,  extremely 
slender-nosed  and  long,  with  rubber  nipple  somewhat  similar 
to  a  medicine  dropper. 

Instead  of  wax  or  other  substances  which  have  been  sug- 


378  THE   CANCER   PROBLEM 

gested  for  the  purpose,  I  have  usually  used  melted  paraffin  for 
injection. 

The  melted  paraffin  is  contained  in  a  vessel  which  floats  in 
a  much  larger  vessel  filled  with  sterile  hot  water,  in  which  is 
placed  a  thermometer.  By  means  of  the  latter  the  paraffin  is 
kept  at  the  required  temperature  (120°  F. — 49°  C).  In  the 
water  of  the  outside  vessel  are  also  placed  the  syringe  and  can- 
nula, which  have  been  previously  securely  connected  by  means 
of  the  rubber  tubing,  all  having  been  sterilized  and  filled  with 
the  melted  paraffin  ready  for  the  injection. 

The  injection  is  made  in  the  following  manner:  At  a  point 
as  close  as  possible  to  the  parotid  gland,  deep  in  the  substance 
of  which  the  two  terminal  branches  are  buried,  the  external 
carotid  is  nicked,  the  cannula  inserted,  and  tied  in  place.  Not 
more  than  2  c.  c.  (30  minims)  of  paraffin  should  be  injected 
into  the  carotid  near  to  where  it  disappears  within  the  parotid 
gland,  this  amount  having  been  proved  by  Dawbarn's  experi- 
ments upon  dogs  to  be  the  safe  amount. 

The  paraffin  is  not  allowed  to  fall  below  108°  F.,  at  which 
temperature  it  solidifies.  By  working  rapidly  the  injection 
may  be  finished  before  this  happens. 

In  order  to  prevent  the  danger  of  clotting  in  the  vessels  to 
be  injected,  it  is  well  to  have  a  duplicate  syringe  and  cannula 
filled  with  warm  normal  salt  solution,  and  to  distend  and  flush 
the  vessels  with  from  10  to  20  c.  c.  of  the  solution  before  pro- 
ceeding to  inject. 

Dawbarn  has  demonstrated  that  there  are  twenty-nine  ways 
by  which  the  external  carotid  system  may  anastomose  with 
other  systems,  chiefly  the  internal  carotid,  and  that  twenty-two 
of  these  (which  are  supplied  by  the  superficial  temporal,  in- 
ternal maxillary  and  occipital  arteries)  may  be  obstructed  with- 
out giving  rise  to  sloughing  of  normal  tissue. 

In  certain  cases,  therefore,  where  the  disease  is  supplied 
with  blood  by  the  occipital  branch,  this  may  also  be  injected. 
When  this  is  to  be  done  it  is  accomplished,  before  the  injection 
of  the  terminal  branches,  in  the  following  manner :  The  other 
branches  of  the  external  carotid  having  been  ligated  as  de- 
scribed, and  this  vessel  itself  tied  low  down  but  not  yet  cut,  it 
is  now  tied  a  second  time,  just  distal  to  the  occipital  branch. 
A  transverse  or  oblique  nick  is  then  made  with  the  scissors  in 
the  wall  of  the  external  carotid  at  a  point  just  proximal  to  the 
branching  of  the  occipital.  The  cannula  is  inserted  into  this 
by  the  aid  of  the  tenaculum,  and  firmly  tied  in  place.  The 
same  amount  of  paraffin  that  is  injected  into  the  carotid,  viz., 
2  c.  c,  or  30  minims,  is  now  injected  into  the  occipital.    When 


SPECIAL  TECHNIC  379 

the  injection  of  the  paraffin  is  completed  the  occipital  is  ligated 
with  catgut  and  cut  through ;  or,  if  solidification  of  the  paraffin 
has  already  taken  place,  the  vessel  may  be  simply  divided. 

In  some  cases  I  have  ligated  and  excised  the  external  carotid 
artery,  according  to  the  technic  described,  without  injecting 
the  terminal  branches.  The  latter  part  of  the  technic  was 
omitted  because  of  the  fear  of  additional  shock.  The  condition 
of  the  patient  must  determine  the  omission  of  this  part  of  the 
operation. 

Possible  abnormalities  in  the  artery  should  always  be  borne 
in  mind.  The  pupil  on  the  side  of  the  ligation  should  be 
watched  when  the  ligature  is  thrown  around  the  external  caro- 
tid. Dilatation  of  the  pupil  upon  compression  of  the  vessel, 
before  the  tie  is  made,  is  indicative  of  an  abnormality,  prob- 
ably the  condition  which  exists  in  the  dog — the  absence  of  an 
external  carotid  artery.  In  such  cases  the  mortality  is  much 
greater  than  in  those  in  which  the  carotid  is  normal. 

It  is  also  to  be  borne  in  mind  that  there  may  be  a  displace- 
ment of  the  external  carotid  artery,  and  that  the  internal  caro- 
tid may  be  ligated  in  its  stead. 

The  procedure  iS  repeated  on  the  other  side  ten  days  later. 
Dawbarn's  experience,  and  that  of  other  surgeons,  including 
my  own,  has  abundantly  proved  that  nothing  short  of  this  seem- 
ingly very  radical  procedure  will  permanently  shut  off  the 
blood  supply  to  the  parts.  Early  anastomosis  takes  place  where 
only  ligation  is  done,  and  the  injection  unquestionably  tends  to 
delay  for  a  much  longer  time  the  establishment  of  collateral 
circulation. 

INDICATIONS    FOR    THE    OPERATION 

It  is  to  be  borne  in  mind  that  the  method  is  employed  only 
in  advanced  cases.  In  the  majority  of  instances,  therefore,  it 
is  merely  palliative.  In  many  cases  the  operation  cannot  be 
employed  because  of  the  great  induration  of  the  tissues,  which 
makes  it  impossible  to  reach  the  artery.  To  cut  into  cancer 
tissue  in  order  to  ligate  the  external  carotid  renders  it  necessary 
subsequently  to  ligate  the  common  carotid,  which  is  a  danger- 
ous procedure,  because,  by  cutting  into  cancerous  tissue,  exten- 
sion of  the  disease  is  apt  to  be  hastened. 

(1)  Age  is  no  bar  to  the  operation,  it  having  been  success- 
fully performed  in  persons  of  ages  ranging  from  early  infancy 
to  extreme  old  age.  In  my  own  experience  the  operation  has 
not  been  done  in  the  case  of  any  very  young  individual,  but 
in  his  essay  Dawbarn  mentions  one  patient,  a  baby  six  months 
old,   upon  whom  a  double  excision  was  performed,   and  an- 


380  THE   CANCER   PROBLEM 

other  eighteen  months  old,  also  a  double  excision.     Recovery 
followed  in  each  case. 

(2)  The  procedure  is  indicated  in  the  treatment  of  car- 
cinoma as  well  as  sarcoma,  although  the  results  have  proved 
more  favorable  in  the  latter  disease.  The  reason  may  be  sought 
in  the  method  of  extension  of  the  two  diseases.  In  carcinoma 
the  lymphatic  system  is  largely  concerned,  the  blood  vessels,  as 
a  rule,  not  being  involved.  Cutting  off  the  blood  supply,  there- 
fore, does  not  prevent  extension,  particularly  upon  or  near  the 
surface,  through  the  lymphatics.  In  sarcoma,  on  the  other  hand, 
the  blood  vessels  are  mostly  concerned  in  the  extension  of  the 
process,  the  lymphatics  rarely  being  involved.  Retardation  of 
growth  and  relief  of  other  symptoms  are  sufficiently  great  in 
carcinoma,  however,  to  warrant  the  employment  of  the  method 
in  cases  where  there  are  no  contraindications. 

(3)  Sometimes,  in  operable  cases,  that  is,  where  the  tumor 
is  wholly  or  partially  removable,  it  may  be  advisable  to  excise 
both  external  carotids  in  order  to  avoid  deformity,  the  patient 
being  kept  under  strict  surveillance  for  any  signs  of  increased 
growth  of  the  tumor. 

(4)  In  operable  cases,  where  the  malignant  growth  is  re- 
movable, but  where  the  disease  is  sufficiently  advanced  to  indi- 
cate probable  early  recurrence,  excision  of  both  external  caro- 
tids may  be  resorted  to  with  the  hope  of  preventing  recurrence. 
Furthermore,  in  such  cases,  this  procedure,  preceding  the  re- 
moval of  the  growth,  insures  an  almost  bloodless  field  and  the 
possibility  of  a  more  extensive  and  thorough  operation. 

( 5 )  In  irremovable  tumors  of  the  base  of  the  tongue,  floor  of 
mouth,  and  pharyngeal  wall,  and  other  inoperable  cancers  of 
the  region  supplied  by  the  external  carotid  and  its  branches, 
the  procedure  may  be  indicated  as  a  measure  of  last  resort. 

It  may  be  said,  in  concluding  the  discussion  of  carotid  ex- 
cision, that  the  objection  sometimes  raised  against  the  method, 
viz.,  possible  gangrene  of  normal  tissue,  has  not  been  substan- 
tiated in  the  experience  of  Dawbarn  and  of  other  surgeons, 
including  my  own.  A  sufficient  blood  supply  remains  to 
maintain  the  vitality  of  the  parts.  The  coldness  and  pallor  of 
the  face,  lips,  and  tongue,  which  are  always  to  be  noted  after 
the  operation,  are  not  of  long  duration. 

The  other  objections,  (1)  injury  to  nerves  with  resultant 
facial  paralysis,  and  (2)  a  possible  fatal  result  arising  from  the 
anomalous  conditions  of  the  arteries  concerned,  are  overcome 
by  a  thorough  knowledge  of  the  anatomy  of  the  parts  and  by 
careful  surgical  technic. 


SPECIAL  TECHNIC 


381 


The  chief  objection,  it  seems  to  me,  to  the  method  as  prac- 
ticed by  Dawbarn  (ligation,  excision,  and  injection),  is  the 
danger  of  shock.  I  have  not  employed  this  procedure  in  a 
large  number  of  cases  for  this  reason,  preferring  to  utilize 
simple  ligation.  In  cases  which  are  too  far  advanced  for  the 
Dawbarn  operation,  because  of  the  involvement  of  the  terminal 
vessels,  simple  ligation  has  been  employed,  going  below  and 
tying  the  external  carotid  on  each  side,  with  whatever  branches 
it  is  possible  to  reach  without  cutting  into  cancerous  tissue. 

The  following  table  summarizes  my  experience  with  the  full 
technic  of  ligation,  excision,  and  injection,  and  with  simple 
ligation  of  the  external  carotid  artery. 

TABLE  I 


Arterial  Ligation  for  Irremovable  Cancer  in  the  Mouth  and  Throat,  etc. 
Report  of  Forty-nine  Cases 

Summary  of  Results 


Case 

Length  of  Life 

Effect  Upon 

Effect  Upon 

xv6in&rkj3. 

No. 

After  Operation. 

Symptoms. 

Hemorrhage. 

1 

Three  Months. 

Improved. 

Controlled. 

2 

Two  Months. 

Improved. 

Controlled. 

3 

Two  Months. 

Improved. 

Controlled. 

Lost  sight  of. 

4 

Three  Months. 

Improved. 

Controlled. 

Lost  sight  of. 

5 

Five  Days. 

Improved. 

Controlled. 

6 

Three  Months. 

Improved. 

Controlled. 

Lost  sight  of. 

7 

Five  Months. 

Improved. 

Controlled. 

8 

Ten  Weeks. 

Improved. 

Controlled. 

9 

Two  Months. 

Improved. 

Controlled. 

Lost  sight  of. 

10 

Two  Months. 

Improved. 

Controlled. 

11 

Five  Months. 

Improved. 

Controlled. 

12 

One  Day. 

Improved. 

Controlled. 

Died  of  Cere- 
bral embo- 
lism. 

13 

One  Month. 

Improved. 

Controlled. 

Lost  sight  of. 

14 

Six  Weeks. 

Improved. 

Controlled. 

15 

One  Month. 

Improved. 

Controlled. 

Lost  sight  of. 

16 

Four  Months. 

Improved. 

Controlled. 

17 

Four  Days. 

Doubtful. 

Controlled. 

18 

Six  Days. 

Doubtful. 

Controlled. 

19 

Two  Days. 

Doubtful. 

Controlled. 

20 

Three  Months. 

Improved. 

Controlled. 

Lost  sight  of. 

21 

Four  Months. 

Improved. 

Controlled. 

Lost  sight  of. 

22 

Three  Months. 

Improved. 

Controlled. 

23 

Five  Months. 

Improved. 

Controlled. 

24 

Five  Months. 

Improved. 

Controlled. 

25 

Two  Days. 

Doubtful. 

Controlled. 

Died  of  Cere- 
bral Apo- 
plexy. 

26 

Four  Months. 

Improved. 

Controlled. 

27 

Nine  Days. 

Doubtful. 

Controlled. 

28 

Ten  Months. 

Improved. 

Controlled. 

582 


THE   CANCER    PROBLEM 


TABLE  I— Continued. 


Case 

Length  of  Life 

Effect  Upon 

Effect  Upon 

Remarks. 

No. 

After  Operation. 

Symptoms. 

Hemorrhage. 

29 

Eleven  Days. 

Doubtful. 

Controlled. 

30 

Two  Months. 

Improved. 

Controlled. 

31 

One  Month. 

Improved. 

Controlled. 

Lost  sight  of. 

32 

One  Day. 

Doubtful. 

Controlled. 

Died  of  Ne- 
phritis. 

33 

Two  Weeks. 

Improved. 

Controlled. 

34 

Five  Months. 

Improved. 

Controlled. 

35 

Three  Months. 

Improved. 

Controlled. 

36 

Six  Weeks. 

Improved. 

Controlled. 

37 

Nine  Weeks. 

Improved. 

Controlled. 

38 

Four  Days. 

Doubtful. 

Controlled. 

39 

Four  Days. 

Doubtful. 

Controlled. 

40 

One  Month. 

Improved. 

Controlled. 

Died  of  Pneu- 
monia. 

41 

Three  Months. 

Improved. 

Controlled. 

Lost  sight  of. 

42 

Seven  Weeks. 

Improved. 

Controlled. 

43 

Eight  Days. 

Doubtful. 

Controlled. 

44 

Three  Months. 

Improved. 

Controlled. 

Living  March 
10,  1914. 

45 

Seven  and  a  half 
Months. 

Improved. 

Controlled. 

Died  of  Pneu- 
monia. 

46 

Two  Months. 

Improved. 

Controlled. 

Died. 

47 

Two  Months. 

Improved. 

Controlled. 

Living  March 
10,  1914. 

48 

One  Month. 

Improved. 

Controlled. 

Died. 

49 

One  Month. 

Improved. 

Controlled. 

Living  March 
10,  1914. 

1. 


3. 

4. 


Summary  of  Results 
Remarks 

Barring  twelve  patients  who  died  from  one  to  eleven  days 

after  operation,  the  length  of  life  varies  from  one  month  to 

ten  months. 

The  effect  upon  symptoms  was   improved   in  thirty-nine 

cases ;  doubtful  in  ten  cases. 

Hemorrhage  was  controlled  in  all  cases. 

Of  the  forty-nine  cases  comprising  this  series,  thirty-six 

died,  ten  were  lost  sight  of,  and  three  were  living  March 

10,  1914. 

Common  carotid 7 

Internal  carotid 1 

Internal  and  external  carotid 1 

Subclavian 1 

Maxillary 1 

Lingual 5 

External  carotid,  right  side 16 

External  carotid,  left  side 16 

Both  external  carotids 1 


SPECIAL   TECHNIC  383 


"STARVATION     LIGATURE,"     WITH     LYMPHATIC     BLOCK,     IN     THE 

TREATMENT  OF  ADVANCED  CANCER  OF  THE 

PELVIC   ORGANS 

HISTORY ' 

The  application  of  the  "starvation  ligature"  to  the  pelvic 
organs  was  first  recorded  bj  Fritsch,  who,  in  1885,  advised  and 
practiced  ligation  of  the  uterine  arteries  in  a  case  of  fibroma 
of  the  uterus.  He  was  followed  by  Hofmeir,  Antal,  Dorsett, 
and  a  number  of  others. 

To  Baumgartner  seems  to  belong  the  credit  for  having  first 
tied  the  uterine  arteries  in  a  case  of  inoperable  cancer  of  the 
uterus,  report  of  which  was  published  in  1888.  The  arteries 
were  ligated  by  way  of  the  vagina  when  this  was  possible,  or 
were  merely  divided  and  clamped.  When  the  vaginal  route 
was  impracticable  he  ligated  the  internal  iliacs  at  the  origin 
of  the  uterine  arteries.  A  number  of  surgeons  followed  him  in 
this  procedure. 

Kelly,  in  1893,  was  the  first  to  ligate  the  internal  iliac  ar- 
teries in  the  treatment  of  cancer  of  the  uterus,  the  procedure 
in  this  case  being  one  of  emergency  to  control  unexpected  and 
otherwise  uncontrollable  hemorrhage.  In  the  course  of  abdom- 
inal hysterectomy  for  squamous-celled  carcinoma  of  the  cervix 
with  extension  to  both  broad  ligaments,  the  ligature  cut  through 
and  free  hemorrhage  ensued.  Both  internal  iliacs  were  ligated, 
the  hemorrhage  was  controlled,  and  the  operation  completed. 
The  patient's  condition  was  such,  however,  that  it  was  impos- 
sible to  remove  all  the  diseased  tissue.  When  readmitted  to 
the  hospital  six  months  later,  to  be  treated  for  a  vesico-vaginal 
fistula,  careful  examination  failed  to  reveal  the  slightest  evi- 
dence of  the  carcinoma.  The  patient  died  ten  months  after  the 
operation.  The  method  was  employed  by  Kelly  and  his  assis- 
tants in  other  cases,  but  they  seem  to  have  abandoned  it  entirely 
during  the  last  few  years. 

One  of  the  most  enthusiastic  advocates  of  the  "starvation 
ligature"  in  the  treatment  of  advanced  cancer  of  the  uterus 
was  the  late  Dr.  William  E.  Pryor,  of  ISTew  York.  In  1896 
he  ligated  the  internal  iliacs  with  the  avowed  purpose,  not  only 
of  controlling  hemorrhage,  but  for  the  "starvation  of  tissue 
which  cannot  safely  be  removed." 

Pryor  ligated,  through  a  median  abdominal  incision,  the 
ovarian,  the  internal  iliac,  and  the  obturator  arteries.  He 
simultaneously  ligated  both  internal  iliacs  in  thirty-four  cases 
1  See  General  Bibliography. 


384  THE   CANCER   PROBLEM 

of  malignant  disease  of  the  uterus,  with  one  fatality.  In  his 
experience  life  was  much  prolonged  and  suffering  diminished. 

It  may  be  recalled  in  this  connection  that  Pryor  advocated 
ligation  of  the  internal  iliac  and  ovarian  arteries  of  each  side, 
not  for  purposes  of  cure,  but  as  a  palliative  measure.  He  con- 
sidered it  an  excellent  means  of  securing  temporary  relief  for 
ineradicable  cancer  of  the  uterus.  In  his  Essay  mentioned 
above,  Dawbarn  quotes  Pryor,  in  this  connection,  as  claiming 
nothing  more  than  this  for  the  method.  "He  has  had  no  real 
cures,  no  permanent  cessations  of  malignant  development,  and 
knows  of  none  at  the  hands  of  others." 

From  1897  to  1900,  Hartmann  and  Fredet  carried  on  a 
series  of  anatomical  investigations  and  published  a  series  of 
articles  on  the  subject  of  ligatures  applied  for  the  purpose 
under  discussion,  and  in  1898,  before  the  Paris  Surgical  So- 
ciety, they  presented  a  series  of  specimens  obtained  from  pa- 
tients who  had  been  operated  upon  for  cancer.  They  concluded 
that  for  purposes  of  hemostasis  ligation  of  the  uterine  artery  is 
superior  to  that  of  the  internal  iliac.  They  were  of  the  opinion 
that  the  course  of  the  malignant  tumor  is  not  apparently  mod- 
ified by  the  ligation.  The  results  noted  were  temporary  dimin- 
ution of  hemorrhages  and  offensive  discharges. 

Tuffier,  at  the  Paris  Surgical  Congress  in  1897,  advocated 
the  ''starvation  ligature"  in  the  treatment  of  inoperable  malig- 
nant growths  of  the  uterus.  This  was  followed  by  a  succession 
of  published  observations  by  Roux,  Morestin,  Jonnesco, 
Hanow,  and  others. 

Pozzi,  in  his  treatise  on  gynecology,  mentioned  the  starva- 
tion ligatures  merely  to  condemn  them,  while  many  others, 
both  in  Europe  and  America,  in  discussing  the  treatment  of 
irremovable  cancer  of  the  uterus  (generally  designated  "in- 
operable"), mentioned  the  subject  in  the  most  casual  manner 
or  neglected  it  entirely. 

In  1904  Rouville,  in  collaboration  with  Martin,  published 
a  series  of  cases  in  which  the  starvation  method  was  employed, 
with  absolutely  no  effect  upon  the  development  of  cancer  of  the 
uterus.    It  was  considered,  however,  a  good  palliative  measure. 

In  1905  Zykow,  a  Russian  surgeon,  published  a  summary  of 
five  cases  in  which  he  employed  complex  or  multiple  ligatures, 
with  resulting  retardation  of  growth,  amelioration  of  the  usual 
symptoms,  and  improvement  of  the  general  condition. 

The  subject  was  next  brought  to  notice  by  P.  Cantier,  who, 
in  1907,  reviewed  the  history  of  the  "starvation  ligature," 
summarized  many  of  the  published  cases,  and  formulated  his 
own  conclusions.     This  contribution  was  called  forth  by  one  of 


SPECIAL   TECHNIC  385 

de  Rouville's  cases,  in  which  the  uterine  arteries  were  ligated, 
with  resulting  control  of  hemorrhage,  but  progressive  develop- 
ment of  the  neoplasm. 

In  1908,  at  the  Annual  Clinical  Lecture  on  Malignant  Dis- 
ease, at  the  New  York  Skin  and  Cancer  Hospital,^  I  presented 
several  patients  and  cited  the  histories  of  others  (Cases  I,  II, 
III,  IV,  and  V  of  the  appended  table),  operated  upon  for  irre- 
movable pelvic  cancer,  according  to  the  earlier  method  which  I 
had  employed  in  these  cases. 

From  the  various  cases  reported  there  may  be  deduced  quite 
enough  evidence  of  a  favorable  nature  to  warrant  a  wider  appli- 
cation of  the  method  in  the  treatment  of  irremovable  cancer  of 
the  pelvic  viscera  than  is  now  being  made.  Jonnesco,  for  exam- 
ple, reports  eight  cases  of  inoperable  cancer  in  which  he  em- 
ployed complex  ligatures,  with  the  result  of  arrest  of  hemor- 
rhages and  discharge,  spontaneous  elimination  of  the  neoplastic 
products,  and  improvement  of  the  patient's  general  condition 
for  six  and  ten  months.  (Congres  International  de  1900, 
Paris. ) 

My  experience,  extending  through  seven  years,  leads  me  to 
conclude  that  arterial  ligation  for  irremovable  cancer  of  the 
pelvic  organs,  to  be  effective  either  in  controlling  hemorrhage 
or  in  checking  the  malignant  growth,  must  be  employed  with 
reference  to  the  possibilities  for  free  anastomosis  to  the  ves- 
sels supplying  these  organs.  The  vessels  cannot,  as  in  the 
case  of  the  external  carotid,  be  subjected  to  any  more  procedure 
than  ligation  in  two  places  and  division  between  the  ligatures, 
and  consequently  it  is  necessary  to  ligate  as  many  of  the  vessels 
as  possible  without  causing  death  of  normal  tissue.  My  ex- 
perience, therefore,  is  not  in  keeping  with  that  of  Fredet,  who, 
as  already  noted,  believed  ligation  of  the  uterine  arteries  to  be 
more  effective  in  controlling  hemorrhage  than  ligation  of  the 
iliac  trunks.  On  the  contrary,  ligation  of  the  uterine  arteries 
alone  is  not  always  sufficient  to  control  hemorrhage  or  check  the 
growth  of  the  neoplasm,  nor  is  ligation  of  the  utero-ovarian 
arteries  sufficient  in  all  cases,  a  fair  blood  supply  to  the  parts 
being  maintained  through  anastomosis  of  other  branches  of  the 
internal  iliac,  or  possibly  through  the  establishment  of  a  re- 
current circulation. 

Ligation  of  the  internal  iliac  artery  of  each  side  close  to  the 
bifurcation  of  the  common  iliac,  thus  shutting  off  all  the 
branches  of  the  posterior  and  anterior  trunks  of  the  first-named 
artery,  eliminates  the  chief  blood  supply  of  the  uterus,  vagina, 
and  pelvic  fascia.     If  they  are  accessible  without  cutting  into 

1  Bainbridge. — See  General  Bibliography. 


386  THE   CANCER   PROBLEM 

cancerous  tissue,  and  if  it  is  deemed  necessary  or  advisable,  the 
procedure  may  be  made  more  thorough  by  ligating  individually 
the  obturator,  superior  vesical,  or  other  branches  of  the  internal 
iliac,  in  addition  to  the  main  ligature  of  this  vessel. 

The  deep  epigastric  and  its  branches,  from  the  external 
iliac ;  the  ovarian,  which  arises  from  the  abdominal  aorta ;  and 
the  sacra  media,  which  arises  from  the  abdominal  aorta  and 
partly  supplies  the  lower  lumbar  and  sacral  region,  including 
the  posterior  surface  of  the  rectum  and  mesorectum,  furnish 
further  possibilities  of  anastomosis.  If,  in  addition  to  the  in- 
ternal iliacs,  the  ovarians  and  the  sacra  media  are  ligated,  the 
blood  supply  is  sufficiently  lessened  to  control  immediate  or 
possible  subsequent  hemorrhage,  and  to  offer  a  reasonable  hope 
of  checking  the  growth  of  the  neoplasm. 

From  the  above  it  will  be  seen  that  failure  in  many  in- 
stances may  have  been  attributable  to  the  fact  that  the  ligation 
was  not  sufficiently  extensive  to  control  the  blood  supply  to  the 
pelvic  organs,  thus  proving  ineffective  in  either  of  the  pur- 
poses for  which  it  is  mainly  applied.  I  have  personally  found 
this  to  be  the  case,  and  accordingly  have  gradually  extended 
the  method.  In  the  communication  mentioned  above,  under 
the  head  of  ''Tying  off  vessels  in  the  pelvis,"  the  following 
statement  is  made:  "The  ovarian  and  uterine  arteries,  or,  if 
the  uterine  cannot  be  reached,  its  nearest  branches,  may  be  tied 
off;  or  the  anterior  division  of  the  internal  iliac  artery  may 
be  ligated  on  the  side  of  the  most  extensive  disease,  the  uterine 
and  ovarian  of  the  opposite  side  being  ligated  at  the  same 
time." 

While  this  procedure  was  advantageous,  as  shown  in  the 
histories  of  two  cases  reported  in  the  article  mentioned  (Cases 
I  and  III  of  the  appended  table),  the  amplified  technic  now 
employed  is  of  greater  promise  because  it  allows  the  freer  ap- 
plication of  other  methods  of  treatment,  surgical  or  non-surgi- 
cal, and  still  further  lessens  the  danger  of  hemorrhage,  while 
increasing  the  possibility  of  checking  the  extension  of  the  ma- 
lignant process.  In  suitable  cases  both  internal  iliacs  just 
below  the  bifurcation  of  the  common  iliac,  both  ovarians,  and 
the  sacra  media  are  now  ligated.  In  some  instances  it  is  neces- 
sary to  ligate  the  common  iliac  just  above  the  bifurcation,  as  in 
Cases  VII  and  XIV. 

THE  PTIRPOSES  OF  THE  METHOD 

I.  To  Control  Hemorrhage. —  (1)  As  an  immediate  life- 
saving  measure;  (2)  to  render  possible  necessary  surgical 
measures;  (3)  to  insure  the  patient  against  the  possibility  of 


SPECIAL   TECHNIC  387 

death   from  hemorrhage   during  the   progress  of   irremovable 
cancer. 

In  many  instances  the  alarming  hemorrhage  is  the  first 
symptom  which  causes  the  patient  to  consult  the  surgeon.  Life 
is  not  infrequently  in  immediate  danger,  and  in  such  cases, 
even  where  little  else  can  be  done  surgically,  life  may  be  pro- 
longed and  mental  and  physical  suffering  mitigated  by  ligating 
the  arteries  as  indicated.  In  cancer  of  the  cervix,  where 
curettage  for  removal  of  necrotic  debris  is  indicated,  the  pro- 
cedure may  cost  the  life  of  the  patient  from  hemorrhage,  unless 
the  curettage  is  preceded  by  ligation.  An  illustration  of  this 
occurred  some  time  ago  in  the  New  York  Skin  and  Cancer 
Hospital.  One  patient  refused  laparotomy.  She  was  curetted 
and  everything  done  for  her  that  was  possible  under  the  cir- 
cumstances, but  she  died  in  the  hospital  some  weeks  later  from 
hemorrhage  which  could  not  be  controlled  by  styptics  and  pack- 
ing. Another  patient  (Case  XL),  who  occupied  a  bed  in  the 
same  ward  at  the  same  time,  submitted  to  laparotomy,  the  ves- 
sels were  ligated,  after  which  curettage  was  done.  The  patient 
gained  flesh  and  strength,  left  the  hospital  in  due  time,  and 
lived  many  months.  Another  illustrative  instance  is  Case  VIII 
of  the  appended  table. 

II.  To  Chech  Extension  of  Malignant  Growth. — The 
assumption  that  a  malignant  process  may  be  checked  by  cut- 
ting off  the  blood  supply  to  the  affected  part  seems  to  have  been 
amply  demonstrated  by  the  recorded  cases,  although,  as  noted 
above,  it  must  be  admitted  that  there  is  a  wide  divergence  of 
opinion  on  the  subject.  In  some  instances,  where,  because  of 
the  circumscribed  nature  of  the  growth,  the  possibilities  of  a 
more  complete  cutting  off  of  the  blood  supply  were  greater,  as 
in  the  cases  reported  by  Packard,  Treves,  Wherry,  and  others, 
cure  seemed  to  follow  the  procedure. 

This  naturally  leads  to  the  conclusion  that,  if  in  advanced . 
cases  there  is  any  real  retardation  of  the  process,  even  though  it 
be  temporary,  then,  in  cases  not  so  far  advanced,  where  the 
method  may  be  applied  without  injury  of  any  kind,  the  possi- 
bilities for  permanent  arrest  of  growth  warrant  a  wider  applica- 
tion of  the  starvation  treatment  than  has  yet  been  made. 

The  method  was  employed  in  cases  herewith  reported  solely  as 
a  palliative  measure,  yet  it  is  fair  to  assume  that  the  extension 
of  the  process  was  checked  to  some  extent,  as  judged  from  the 
improvement  in  the  patients'  general  condition,  the  lessening 
of  fetor  and  other  symptoms  of  advanced  cancer  of  the  pelvic 
organs. 

III.  To  Mitigate  Physical  Pain  and  Mental  Suffering. — 


388  THE   CANCER   PROBLEM 

In  many  cases  the  pressure  resulting  from  the  growth  gives 
rise  to  intense  suffering,  which  is  relieved  or  greatly  les- 
sened by  the  shrinkage  which  follows  the  ligation  of  the  nutri- 
ent vessels  to  the  diseased  parts.  This  shrinkage  is  sometimes 
noted  by  those  witnessing  the  operation.  As  soon  as  the  vessels 
are  ligated  the  parts  are  seen  to  pale  and  perceptibly  diminish 
in  size.  Attention  has  already  been  called  to  the  relief  of  other 
pressure  or  constriction  s_>anptoms,  made  possible  by  the  con- 
trol of  the  blood  supply,  as  in  breaking  up  non-cancerous  ad- 
hesions, freeing  the  ureter,  etc. 

IV.  To  Diminish  Absorption  of  Poisonous  Products. — 
The  sepsis  which  is  characteristic  of  advanced  cancer  is  not 
always  from  the  cancer  of  the  uterus,  but  from  the  broken-down 
glands  in  the  pelvis.  The  method  not  only  facilitates  the  re- 
moval of  glands  between  the  uterus  and  the  receptaculum  chyli, 
but  it  in  a  measure  shuts  off  the  lymphatic  avenues  of  absorp- 
tion. Cachexia  is  thus  lessened,  and  the  patient  is  rendered 
more  amenable  to  measures  which  tend  to  promote  elimination. 
This  paves  the  way  for  general  tonic  treatment,  which  is  of 
little  or  no  avail  when  the  system  is  thoroughly  clogged  and 
poisoned  by  the  absorption  of  toxic  products. 

V.  To  Facilitate  the  Discharge  of  Pus  and  Necrotic 
Tissue. — It  is  of  the  utmost  importance  that  a  free  outlet  for 
pus  and  necrotic  tissue  be  maintained.  In  some  cases  this  is 
impossible  without  danger  of  fatal  or  exhaustive  hemorrhage, 
and  consequently  it  is  no  common  thing  to  find  acetone  or  other 
styptic  or  cauterant  agents  applied  to  the  cervix,  so  constricting 
the  outlet  that  the  pus  and  necrotic  debris  are  dammed  up  in 
the  uterine  cavity.  Sometimes,  by  inserting  the  finger  into  the 
OS  and  pressing  upon  the  fundus,  a  gush  of  pus  follows.  With 
the  vessels  securely  ligated,  the  uterus  may  be  curetted  away 
to  a  shell,  allowing  free  exit  to  discharges  without  fear  of 
hemorrhage.  Once  thoroughly  cleared,  the  discharge  grows 
less,  and  naturally  the  fetor  is  diminished. 

VI.  To  Permit  the  Application  of  Other  Surgical  and 
Non-surgical  Measures. — Curettage;  cauterization  by  the 
Byrne  method;  the  application  of  thermic  coagulation  or 
thermoradiotherapy;  the  employment  of  ionic  surgery,  accord- 
ing to  the  method  of  Betton-Massey ;  the  intelligent  and  syste- 
matic use  of  acetone  and  other  caustics;  the  use  of  radium  and 
radiogelatin,  if  desired;  the  trial  of  the  various  non-surgical 
methods  of  treatment  which  from  time  to  time  are  proposed; 
and  the  institution  of  the  necessary  hygienic  and  dietetic  re- 
gime, are  all  facilitated  by  preliminary  ligation  of  the  arteries, 
as  described.     Furthermore,  a  great  deal  more  can  sometimes 


SPECIAL   TECHNIC  389 

he  accomplished  surgically  than  seemed  feasible  before  the 
abdomen  was  opened.  It  is  even  possible,  in  some  cases,  to 
extirpate  the  uterus  where  this  seemed  entirely  out  of  the 
question  before  laparotomy.  Volvulus  and  other  abnormal  con- 
ditions of  the  intestines,  causing  obstruction  or  other  symp- 
toms, may  be  discovered  and  corrected  upon  opening  the  abdo- 
men for  purposes  of  ligation.  Cases  IX,  XIII,  and  XIV,  of 
the  appended  table  are  illustrations  of  this. 

In  many  cases  the  patient  is  dying  not  so  much  from  the 
cancer  per  se  as  from  the  absorption  of  toxic  products,  some 
of  which  do  not  emanate  from  the  cancer.  In  the  effort  to 
relieve  suffering,  morphin  is  often  given  in  enormous  doses. 
As  a  consequence  there  is  a  veritable  locking  up  within  the 
body  of  poisons  which  now,  even  more  than  under  other  cir- 
cumstances, need  to  be  eliminated.  Furthermore,  in  the  effort 
to  keep  up  the  vitality,  large  quantities  of  milk  are  given, 
which  it  is  often  difficult  for  the  patient  to  assimilate  or 
eliminate.  Thus,  well-meant  attempts  to  aid  are  in  reality 
merely  hastening  the  end.  How  much  better,  then,  in  suitable 
cases,  to  ligate  the  vessels  as  described,  thus  obviating  the  dan- 
ger of  hemorrhage,  while  opening  up  the  avenues  for  the  escape 
of  poisons,  and  fitting  the  patient  for  receiving  the  fullest 
benefits  from  whatever  medicinal,  dietetic,  or  hygienic  meas- 
ures may  be  employed. 

OBTECTIONS  WHICH  MAY  BE  EAISED  TO  THE  FROCEDimE 

(1)  That  it  is  impossible  to  get  at  the  vessels  without  ex- 
tensively entering  cancerous  tissues.  If  this  were  really  true 
in  all  cases,  naturally  the  operation  would  have  no  place  of 
usefulness  in  surgery  for  cancer,  for,  as  I  have  already  said, 
it  is  imperative  not  to  cut  into  cancerous  tissue  and  thus  dis- 
seminate cancer  cells.  But  it  is  rarely  true.  In  many  in- 
stances extensive  adhesions  are  the  result  of  old  inflammatory 
processes  having  nothing  whatever  to  do  with  the  cancer,  and 
probably  of  prior  existence  to  it. 

(2)  That  enlarged  glands  around  the  bifurcation  of  the 
common  iliac  may  be  encountered  and  cut  into.  Unless  such 
glands  are  broken  down,  which  is  very  uncommon,  it  is  possible 
to  dissect  them  out.  In  Case  II  of  the  table  the  disease  had  so 
softened  the  bifurcation  of  the  common  iliac  on  the  right  side 
that  it  would  have  been  only  a  very  short  time  until  the  vessel 
would  have  given  way  and  death  from  hemorrhage  or  profound 
sepsis  would  have  ensued. 

(3)  That  it  is  impossible  to  reach  and  ligate  the  arteries 


390  THE   CANCER   PROBLEM 

without  harm  to  the  ureters.  Such  an  objection  is  void  when 
the  operation  is  performed  by  one  whose  skill  is  sufficient  to 
warrant  undertaking  the  operation  at  all.  The  ureters  are  easily 
identified  and  injury  to  them  readily  avoided. 

(4)  That  gangrene  may  follow  cutting  off  the  blood  supply, 
particiilarly  that  terrible  sloughing  may  follow  in  cases  where 
the  bladder  and  rectum  are  involved.  Of  course  it  is  under- 
stood that  complete  and  absolute  deprivation  of  blood  to  any 
part  means  its  death  en  masse.  This  does  not  apply  in  the 
method  here  described,  inasmuch  as  an  ample  blood  supply  is 
left  for  the  maintenance  of  vitality.  The  objection  with  refer- 
ence to  the  bladder  and  rectum  is  discussed  in  the  next  section. 

INDICATIONS 

It  is  not  to  be  inferred  that  arterial  ligation  with  lymphatic 
block  is  advocated  in  all  cases  of  advanced  cancer  which  are 
no  longer  amenable  to  the  usual  surgical  methods  for  the  re- 
moval of  cancer  of  the  pelvic  organs.  It  may  be  advised  under 
the  following  circumstances : 

(1)  When  hemorrhage,  which  threatens  death,  cannot  be 
controlled  by  other  measures. 

(2)  When  hemorrhage  has  been  sufficiently  severe  or  fre- 
quent to  warrant  fear  of  fatal  return  at  any  time. 

(3)  When  hemorrhage  is  sufficient  to  cause  a  constant  drain 
on  the  patient's  vitality. 

(4)  When  the  disease  is  so  extensive  as  to  render  curettage 
dangerous  because  of  hemorrhage. 

(5)  When  there  is  reason  to  believe  that,  by  controlling,  to 
a  certain  extent,  the  progress  of  the  disease,  the  pain,  fetor, 
and  discharge  may  be  lessened. 

(6)  When  it  is  possible,  by  this  means,  to  relieve  various 
pressure  symptoms. 

(7)  When,  in  the  presence  of  advanced  cancer  of  the  pelvic 
organs,  other  conditions  which  may  not  be  directly  due  to  the 
cancer  call  for  exploratory  laparotomy. 

(8)  When,  in  cases  seemingly  too  far  advanced  for  total 
extirpation  with  hope  of  permanent  cure,  there  is  yet  a  pos- 
sibility that  life  may  be  prolonged  and  suffering  relieved,  and 
in  some  cases  a  radical  cure  effected.  Case  26  is  an  illustration 
of  this  condition. 

(9)  When  all  other  measures  have  failed  to  give  any  relief 
from  the  symptoms  in  the  given  case,  when  the  patient  de- 
mands that  something  more  be  done,  and  when  there  is  any 
hope  of  mitigating  suffering  or  prolonging  life. 


SPECIAL    TECHNIC  $9] 


TECHNIC 


The  steps  of  the  operation  may  be  given  categorically,  as 
they  apply  to  the  average  case: 

(1)  Laparotomy. — The  abdomen  is  opened  by  an  incision 
made  a  little  to  the  right  or  left  of  the  median  line,  the  cut 
being  carried  quickly  through  all  the  tissues,  except  the  rectus, 
v^hich  is  drawn  to  one  side,  down  to  the  peritoneum.  The  ab- 
dominal cavity  having  been  opened,  the  patient  is  placed  in  the 
Trendelenburg  position.  The  intestines  are  displaced  toward 
the  diaphragm,  in  order  to  give  free  access  to  the  pelvis,  being 
dyked  off  with  warm  pads. 

(2)  Ligation  of  Ovarian  Arteries,  with  Double  Oophor- 
ectomy.— The  ovarian  arteries  are  ligated  just  above  the  brim 
of  the  pelvis,  one  place  being  sufficient.  Pagenstecher  thread 
or  strong  silk  is  used  for  this  purpose.  The  upper  part  of  the 
broad  ligament  close  to  the  uterus,  with  the  Fallopian  tube,  is 
tied  off  as  well.  The  ovary,  tube,  and  upper  part  of  the  broad 
ligament,  including  the  parovarian  tissue,  are  exsected. 

(3)  Incision  of  Peritoneum  on  Posterior  Wall  of  Abdomen. 
— This  is  accomplished  by  a  curved  incision  extending  from 
one  internal  iliac  artery  to  the  other,  with  the  convexity  up- 
ward, and  prolonged  downward  along  the  top  of  the  broad  liga- 
ment, already  divided  in  the  preceding  step  of  the  operation. 
As  a  rule  this  gives  free  access  to  all  the  retroperitoneal  struc- 
tures in  the  pelvis. 

(4)  Ligation  of  Internal  Iliac  Arteries. — The  internal  iliac 
artery  of  each  side  is  ligated  m  turn.  The  artery  is  carefully 
separated  from  its  vein  and  ligated  in  two  places.  The  first 
ligature  is  placed  just  below  the  bifurcation  of  the  common 
iliac,  and  the  second,  half  an  inch  below  the  first.  With  a 
large,  plain  clamp  the  artery  is  crushed  between  the  two 
ligatures. 

(5)  Ligation  of  the  Common  Iliac  Artery. — One  may  be 
forced,  unexpectedly,  to  ligate  the  common  iliac  artery.  An 
advanced  atheromatous  condition  of  the  vessel,  with  begin- 
ning erosion  due  to  softening  of  the  glands  at  the  bifurcation, 
may  render  it  necessary  to  ligate  the  common  iliac  just  above 
this  point  in  order  to  obviate  the  danger  of  rupture.  This  pro- 
cedure, of  course,  is  to  be  resorted  to  only  in  such  unforseen 
emergencies.  In  cases  12  and  24  the  common  iliac  of  the  right 
and  left  sides,  respectively,  was  ligated  just  above  the  bifurca- 
tion, with  no  unfavorable  symptoms  in  either  case. 

(6)  Ligation  of  the   Uterine  Arteries. — If  it  can  be   ac- 


392  THE   CANCER   PROBLEM 

oomplished  without  cutting  into  cancerous  tissue,  the  uterine 
arteries  may  be  ligated. 

(7)  Ligation  of  the  Obturator. — What  has  been  said  with 
reference  to  the  uterines  applies  likewise  to  the  obturator. 

(8)  Ligation  of  the  Sacra  Media. — If  large  enough  to  war- 
rant it,  the  sacra  media  is  next  ligated.  One  ligature  is  suffi- 
cient for  this. 

(9)  Lymphatic  Block. — Either  before  or  after  this  ligation 
operation,  the  glands  along  the  iliacs  are  removed  en  masse,  if 
possible,  from  the  receptaculum  chyli  to  the  obturator  foramen. 
The  glands  situated  within  and  around  the  obturator  foramen 
are  removed.  I  have  without  difficulty  removed  the  glands  in 
this  locality,  taking  them  out  en  masse  and  placing  a  hot  pad 
over  the  area.  If  any  of  the  glands  are  so  softened  that  there 
is  danger  of  breaking  them  and  soiling  the  peritoneum,  the 
operator  must  choose  between  the  two  evils — leaving  them  to 
break  down  early  of  themselves,  or  taking  them  out  and  run- 
ning the  risk  of  rupturing  them,  thus  soiling  the  peritoneum. 
The  danger  of  this  contamination  is  slight  if  one  is  careful  to 
pad  off  the  rest  of  the  peritoneum,  and  to  carefully  approxi- 
mate the  edges  of  the  peritoneal  wound,  covering  over  the  raw 
surfaces. 

(10)  Correction  of  Accompanying  Pathological  Conditions. 
— After  completion  of  the  ligation  and  removal  of  the  lymph 
structures,  all  accompanying  pathological  conditions  are  cor- 
rected as  far  as  possible  and  in  proper  sequence.  A  great  deal 
more  can  sometimes  be  accomplished  surgically  than  seemed 
possible  before  opening  the  abdomen.  The  uterus  may  be  ex- 
tirpated in  some  cases  where  such  a  procedure  seemed  impos- 
sible before  laparotomy.  Volvulus,  "kinks,"  and  other  ab- 
dominal conditions  of  the  intestine,  causing  obstructive  and 
other  symptoms,  may  be  discovered  and  corrected  upon  opening 
the  abdomen  for  purposes  of  ligation.  In  many  cases  the  vic- 
tim of  cancer  may  suffer  coincidentally  with  non-malignant 
disease  of  the  ovaries  and  tubes.  Removal  of  these  diseased 
structures  may  relieve  the  symptoms,  the  patient  having  cancer 
but  not  as  yet  suffering  directly  from  it.  There  is  no  reason 
why  a  woman  should  be  handicapped  by  displacement  or  dis- 
ease of  the  ovaries  and  tubes  just  because  she  is  the  victim  of 
cancer.  She  should  be  relieved  if  possible  of  these  conditions 
despite  the  cancer.  The  ovaries,  therefore,  should  be  removed. 
This  is  done  for  the  following  reasons:  (1)  In  accordance 
with  Beatson's  theory  of  the  presumptive  influence  of  ovarian 
irritation  upon  the  cancer  process.  (2)  An  otherwise  normal 
ovai'v  may  be  subjected  to  a  degenerative  process  as  a  result 


SPECIAL    TECHNIC  393 

of  pressure  irritation  by  the  cancer,  or  by  adhesions  later  in 
the  course  of  the  disease,  giving  rise  to  additional  preventable 
discomfort.  (3)  By  cutting  away  the  upper  part  of  the  broad 
ligament,  in  the  removal  of  the  ovary,  a  certain  amount  of  col- 
lateral circulation  is  shut  off,  thus  facilitating  the  lessening  of 
the  blood  supply  to  the  cancer. 

(11)  Closure  of  the  Ahdominal  Wall. — The  posterior  layer 
of  peritoneum  is  closed,  the  intestines  and  omentum  are  re- 
placed in  position,  and  the  anterior  layer  of  peritoneum  is 
brought  together  with  a  few  simple  stitches.  For  purposes  of 
expedition  the  abdominal  wall  is  then  often  closed  en  masse 
with  through-and-through  sutures  of  silkworm  gut  or  silk 
thread. 

(12)  Curettage. — After  the  abdomen  is  closed  the  patient 
is  placed  in  the  lithotomy  position  and  thorough  curettage,  by 
the  Byrne  or  other  method,  may  be  resorted  to  when  circum- 
stances warrant.  With  the  arteries  ligated  as  above  described, 
the  uterus  may  be  curetted  to  a  shell  without  danger  of  hemor- 
rhage. Zinc  chlorid  or  acetone  may  be  applied  to  the  interior 
of  the  uterine  cavity,  or,  if  feasible,  thermocoagulation  may  be 
employed.^  Curettage  and  the  adjuvant  measures  mentioned 
may  be  employed  immediately  after  the  ligation  operation,  or 
a  week  or  ten  days  later,  by  which  time  the  tissues  will  be  much 
more  contracted.     I  prefer  the  latter. 

SPECIAL  POINTS   OF  TECHNIC   TO  BE   OBSERVED 

Success  or  failure  in  arterial  ligation  with  lymphatic  block 
is  dependent  upon  various  features — the  extent  of  the  disease, 
the  patient's  general  state,  and  the  complicating  pathological 
conditions.  Aside  from  all  these,  however,  success  is  largely 
dependent  upon  certain  points  of  technic  which  should  be  borne 
in  mind : 

(1)  Adhesions. — If  cancerous  adhesions  are  very  extensive, 
so  that  it  is  necessary  to  break  them  up  in  order  to  reach  and 
ligate  the  vessels,  the  operation  is  contraindicated.  Extensive 
adhesions  sometimes  result  from  old  inflammations,  and  may 
have  no  relation  to  the  cancer  so  far  as  their  origin  is  con- 
cerned. Inflammatory  adhesions  may  be  safely  dealt  with  and 
the  vessels  ligated.  It  is  important,  therefore,  to  differentiate 
between  malignant  and  non-malignant  adhesions. 

1  Bainbridge. — (1)  "The  de  Keating-Hart  Method  of  Fulguration  and 
Thermoradiotherapy,"  Medical  Record,  July  6  and  20,  1912;  (2)  "Ful- 
guration and  Thermoradiography, "  The  Jour,  of  Advanced  Therapeutics, 
January,  1913. 

See  also:  The  International  Clinics,  September,  1913,  and  The  Refer- 
ence Eandboolc  of  Medical  Sciences,  September,  1913. 


394>  THE   CANCER   PROBLEM 

(2)  Cicatricial  Contractions. — Cicatricial  contractions  in 
the  diseased  tissue  frequently  cause  pressure  upon  the  ureter, 
which  otherwise  may  not  be  involved  in  the  malignant  process. 
In  such  event  the  ureter  may  be  stripped  up  without  breaking 
the  cancerous  adhesions,  thus  relieving  pressure  in  the  neigh- 
borhood. If  the  ureter  is  directly  involved  in  the  cancer  this 
does  not  apply.  Separation  of  the  ureter  is  accomplished  by 
inserting  the  finger  or  a  blunt  instrument  between  it  and  the 
connective  tissue  which  lies  over  the  cancerous  tissue,  and 
carefully  working  the  ureter  free. 

(3)  Occlusion  of  Ligatcd  Artery. — The  entire  success  of 
the  operation  may  be  nullified  by  failure  to  occlude  the  vessels 
ligated.  Complete  closure  is  rendered  certain  by  ligating  in 
two  places  and  crushing  the  artery  between  the  two  ligatures. 

(4)  Hemostasis. — Absolute  hemostasis  is  important.  Ooz- 
ing from  veins  may  be  controlled  with  pads  dipped  in  hot  saline 
solution  and  left  in  place  on  one  side  while  attending  to  the 
other. 

(5)  Removal  of  Glands. — In  dealing  with  suspicious 
glands  situated  directly  in  contact  with  large  blood  vessels,  one 
must  be  careful  to  ascertain  whether  they  are  softened  under- 
neath, while  apparently  normal  on  the  surface.  Failure  to 
note  such  conditions  may  lead  to  rupture  of  an  underlying  or 
contiguous  blood  vessel,  or  to  the  soiling  of  the  peritoneum  by 
the  breaking  of  such  softened  glands. 

(6)  Injury  to  Iliac  Veins. — Care  must  be  taken  not  to 
injure  the  internal  iliac  vein,  which  lies  just  to  the  mesial  side 
and  behind  the  artery.  This  is  the  greatest  danger  of  the 
operation. 

CLINICAL    APPLICATION 

As  previously  stated,  the  operation  of  arterial  ligation  with 
lymphatic  block  is  distinctively  a  procedure  for  advanced  can- 
cer of  the  pelvic  organs,  in  which  the  disease  has  progressed 
to  such  a  stage  that  complete  removal  is  impossible.  However, 
if  the  method  were  employed  earlier  in  the  course  of  malignant 
development,  better  results  would  doubtless  be  obtained.  Lat- 
terly I  have  had  recourse  to  this  procedure  earlier  than  for- 
merly, and  in  such  cases  the  results  have  been  very  satisfactory. 
When  the  cancer  has  become  disseminated,  especially  when  it 
has  progressed  to  the  stage  characterized  by  vesico-vaginal  fis- 
tula, it  is  too  late  to  hope  for  very  much.  In  Case  43,  however, 
a  patient  with  vesico-vaginal  fistula  was  alive  and  able  to  work 
seven  months  after  operation.  The  tendency  should  be  toward 
an  earlier  rather  than  a  later  application  of  the  method. 


SPECIAL   TECHNIC  395 

Cases  of  advanced  cancer  in  the  wards  of  the  "New  York 
Skin  and  Cancer  Hospital  in  which  ligation  has  been  employed 
have  been  compared  with  others,  there  at  the  same  time,  in 
which  it  was  not  resorted  to,  and  it  has  been  found  that  in  the 
former  cases  the  patients  are  far  more  comfortable,  and  progress 
much  more  satisfactorily  than  in  the  latter. 

The  appended  table  summarizes  fifty-six  cases  in  which  ar- 
terial ligation  with  lymphatic  block  was  employed  in  advanced 
cancer  of  the  pelvic  organs.  It  is  to  be  remembered  that  the 
majority  had  already  undergone  one  or  more  operations,  or  had 
been  told  that  there  was  no  hope  for  them.  Many  were  stupefied 
with  sedative  drugs,  and  were  merely  waiting  for  the  relief 
which  comes  with  death. 


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Because  of  the  advanced 
stage  of  the  disease,  this 
case  was  an  unfavorable 
one   for   operative   inter- 
ference, but  in  view  of  the 
following  facts  it  was  de- 
cided to  resort  to  hgation 
as  a  last  hope  of  relief :  (1) 
The    increasing    intensity 
of  the  pain.    (2)  The  fre- 
quency   and    severity    of 
the  hemorrhages,  which  it 
was  impossible  to  control 
by  other  means.    (3)  The 
patient^s  piteous  plea  that 
something  be  done  to  re- 
heve  her.    A  mistake  was 
made  in  this  instance  in 
ligating   the   broad   hga- 
ments,    which    were    in- 
volved  in  the  cancerous 
process,  and  in  breaking 
up  some  of  the  cancerous 
adhesions.     The  internal 
iliacs  could  not  be  reached 
for  ligation.    Septic  peri- 
tonitis   supervened,    and 
the  patient  died  the  day 
following  operations.  (No. 
33  of  Enzjine  Report). 

Patient  hved  many  months, 
able  to  do  light  housework. 
Was    present    at    annual 
chnic,  in  May,  1909,  one 
year  after  operation.  (No. 
80  of  Enzj-me  Report). 

s 

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Markedly  lessened. 
Markedly  lessened. 
Markedly  lessened  - 
None  present. 
Apparently  checked. 
Greatly  improved. 

Mitigated. 
Lessened  somewhat. 
Lessened  somewhat. 
None  present. 
Doubtful. 
Improved. 

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ment with  many  ad- 
hesions, some  of  which 
were   cancerous;    tis- 
sues very  friable;  dis- 
ease irremovable.  In- 
testines and  parietes 
bathed    in    purulent 
fluid;   a  pool  of  pus 
found  in  pelvis.    Pos- 
terior surface  of  blad- 
der and  a  contiguous 
loop  of  gut  gangre- 
nous. 

Extensive  involvement 
of  uterus,  broad  liga- 
ments  and    bladder; 
vesico-vaginal  fistula; 
irremovable. 

Irremovable  cancer  of 
uterus    and    adnexa 
with  extension  to  cul- 
de-sac  of  Douglas  and 
posterior  wall  of  blad- 
der. 

Double  oophorectomy. 

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with  extension  to 
abdominal   vis- 
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1.  Carcinoma     of 
uterus  and  blad- 
der. 

2.  Carcinoma. 

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411 


412  THE   CANCER    PROBLEM 


RESPIEATORY  SYSTEM 

Tracheostomy  is  employed  for  the  relief  of  obstruction  in 
cases  of  irremovable  cancer  of  the  larynx  or  other  structures 
high  up  in  the  neck.  The  artificial  opening  must  be  below  the 
disease. 

ALIMENTARY  SYSTEM 

Palliative  procedures,  directed  chiefly  toward  the  relief  of 
obstruction  caused  by  irremovable  cancer,  are  applicable  to 
various  portions  of  the  alimentary  tract. 

Esophagostomy  is  resorted  to  in  advanced  cancer  of  the 
mouth,  tongue,  or  pharynx,  particularly  if  the  disease  is  suffi- 
ciently extensive  to  cause  obstruction.  The  artificial  opening 
should  be  made  as  low  down  as  possible,  with  the  hope  of  escap- 
ing extension. 

Gastrostomy  is  advocated  by  some  surgeons,  and  deprecated 
by  others,  for  the  relief  of  obstruction  in  cancer  of  the  pharynx, 
esophagus,  and  cardiac  end  of  the  stomach.  It  is  held  by  some 
that  the  relief  is  not  sufficient  to  warrant  the  operation.  Others 
call  attention  to  the  possibility  of  an  error  in  diagnosis,  by 
which  a  patient  is  unnecessarily  condemned  to  this  mode  of 
taking  nourishment.  Excluding  mistakes  in  diagnosis,  it  can- 
not be  gainsaid  that  a  patient  should  not  be  allowed  to  die  of 
starvation  when  there  is  a  possibility  of  relief  by  gastrostomy. 

Gastro-enterostomy,  or  anastomosis  between  the  stomach  and 
some  portion  of  the  small  intestine,  is  advocated  when  cancer  of 
the  stomach  causes  obstruction  at  the  pyloric  outlet. 

The  terms  "anterior"  and  "posterior"  are  employed  when 
the  union  is  made  to  the  anterior  or  posterior  wall  of  the 
stomach. 

The  operation  is  more  specifically  designated  "gastro-duo- 
denostomy,"  or  "gastro-jejunostomy,"  when  the  union  is  made 
between  the  stomach  and  the  duodenum  or  the  jejunum,  respec- 
tively. 

Colostomy,  or  the  making  of  an  artificial  anus,  is  employed 
by  some  surgeons  for  the  relief  of  obstruction  in  cancer  of  the 
colon.  The  opening  may  be  placed  in  the  lumbar  region  (lum- 
bar colostomy),  or  in  the  right  or  left  groin  (right  inguinal 
colostomy,  left  inguinal  colostomy,  or  sigmoidostomy,  respec- 
tively). 

When  the  operation  is  carefully  performed  and  a  properly 
constructed  pad  is  employed,  the  colostomy  opening  may  prove 
very  satisfactory.     In  many  instances,  however,  the  artificial 


SPECIAL   TECHNIC  413 

anus  does  not  work  well,  the  support  is  not  properly  adjusted, 
and  leakage  is  the  inevitable  result. 

**Short-circuit." — In  many  cases  in  which  colostomy  is  ad- 
vocated by  some  surgeons,  a  short-circuiting  operation  would 
answer  the  purpose  more  satisfactorily.  By  this  means  the 
affected  portion  of  the  gut  is  thrown  out  of  use  by  uniting  the 
intestine  above  and  that  below  the  disease.  The  point  of  union 
should  be  at  as  great  a  distance  as  feasible  from  the  growth, 
in  order  to  allow  the  patient  a  considerable  length  of  life  before 
the  disease  again  encroaches  upon  the  caliber  of  the  intestine. 

Colectomy,  or  the  removal  of  a  portion  of  the  colon,  may  be 
done  even  in  the  presence  of  apparent  metastatic  disease  in 
glands  which  are  high  up,  perhaps  under  the  liver.  The  in- 
volvement of  the  glands,  however,  may  be  inflammatory,  and 
removal  of  the  colon,  with  end-to-end  anastomosis,  or  with 
closure  of  both  ends  and  anastomosis  between  the  ascending  and 
the  descending  colon,  may  effect  a  cure  of  the  malignant  dis- 
ease in  the  gut.  In  one  case  in  which  I  performed  this  opera- 
tion six  years  ago  there  was  apparent  extension  of  the  cancer 
into  the  glands  back  of  the  liver.  These  were  distinctly  en- 
larged, but  could  not  be  removed.  The  fact  that  the  patient  is 
well  after  six  years  leads  to  the  conclusion  that  the  glands  were 
not  the  seat  of  malignant,  but  of  inflammatory,  involvement. 


URINARY    SYSTEM 

Cystostomy,  or  artificial  opening  in  the  bladder,  is  indicated 
when  a  malignant  neoplasm  of  the  bladder,  urethra,  or  prostate, 
causes  obstruction  to  the  passage  of  urine  from  the  bladder. 
The  situation  of  the  growth  determines  whether  the  opening 
should  be  suprapubic  or  perineal. 

Nephrotomy,  or  drainage  of  the  kidney  through  an  opening 
in  the  loin,  is  employed  when  both  ureters  have  become  closed 
by  the  encroaching  malignant  growth.  The  right  kidney, 
which,  as  a  rule,  is  the  last  affected,  should  be  drained  first. 
The  left  kidney,  which  is  generally  more  extensively  involved 
by  the  time  anuria  results,  need  not  be  opened  so  long  as  the 
other  functionates,  one  active  kidney  being  sufficient  for  the 
maintenance  of  life  during  the  remaining  short  span. 

Ureteral  transplantation  may  be  resorted  to  when  malig- 
nant disease  in  the  vicinity  tends  to  block  off  the  drainage  of 
urine  from  either  kidney.  The  ureter  of  the  affected  side  may 
be  transplanted  into  the  intestine,  or  into  the  loin.  The  latter 
procedure  is  preferred  by  many  surgeons,  because  of  the  ever 


414  THE   CANCER    PROBLEM 

present  danger,  in  the  former  ease,  of  infection  of  the  kidney 
and  death  from  pyelo-nephritis. 


BILIARY  SYSTEM 

Cholecystostomy — the  creation  of  a  permanent  opening  into 
the  gall-bladder  through  the  abdomen — or  Cholecyst-enteros- 
tomy — the  making  of  an  artificial  opening  from  the  gall-bladder 
to  the  intestine — may  greatly  relieve  the  extreme  jaundice 
which  results  when  the  passage  of  bile  is  interfered  with  by 
cancer  of  the  head  of  the  pancreas,  the  bile  papillae  and  biliary 
ducts,  or  the  glands  in  the  portal  fissure. 

I  had  a  case  two  years  ago  in  which  there  was  cancer  at  the 
head  of  the  pancreas,  with  damming  back  of  the  bile  in  the 
gall-bladder.  The  jaundice  was  extreme,  and  the  suffering  of 
the  patient  from  the  intense  and  persistent  itching  of  the  skin, 
which  could  not  be  relieved,  was  almost  intolerable.  Cholecyst- 
enterostomy  gave  great  relief,  and  the  patient  lived,  in  a  fair 
degree  of  comfort,  for  two  years. 

STJMKAKY 

From  a  study  of  the  foregoing  special  methods  it  is  evident 
that  by  various  modifications  of  technic,  and  by  plastic  and 
palliative  measures,  the  chances  of  the  cancer  patient  to-day 
for  permanent  cure,  for  operation  with  a  minimum  of  de- 
formity, and  for  increased  comfort  when  cure  is  no  longer  tc 
be  expected,  are  far  greater  than  they  were  a  few  years  ago. 
The  surgery  of  the  future  will  doubtless  warrant,  in  still  greater 
measure,  the  hope  that  "springs  eternal." 


SECTION    XII 

IRREMOVABLE    CANCER 

INTRODUCTORY  REMARKS 

In  other  sections  we  have  dealt  with  the  earlier  and  more 
hopeful  stages  of  cancer.  We  come  now  to  a  general  considera- 
tion of  the  more  advanced  and  less  hppeful  stages,  to  which 
the  term  "inoperable"  is  so  commonly  and  sometimes  so  care- 
lessly applied.  (Special  methods  which  may  be  employed  in 
the  surgical  treatment  of  advanced  cancer  of  certain  regions  are 
discussed  in  Section  XI,  Chapter  2.) 

For  purposes  of  clarity,  particularly  with  reference  to  treat- 
ment, it  has  been  my  custom  ^  to  classify  advanced  cancer 
under  the  following  heads:  (1)  Seemingly  irremovable;  (2) 
operable,  but  irremovable,  yet  curable;  (3)  operable,  but  irre- 
movable and  incurable;  (4)  inoperable,  irremovable,  and  in- 
curable. 

A  casual  consideration  of  this  classification  suggests  that  the 
word  "inoperable"  in  reality  applies,  in  the  majority  of  in- 
stances, only  to  the  very  last  stage  of  the  disease,  and  to  a 
minority,  perhaps,  of  advanced  cases.  There  never  is  a  time,  in 
the  course  of  the  disease,  when  it  would  be  permissible,  from 
either  a  surgical  or  a  humanitarian  point  of  view,  to  add  in  any 
degree  to  the  already  overwhelming  burden  of  mental  and  phys- 
ical suffering  which  usually  accompanies  advanced  cancer,  with- 
out a  distinct  hope  of  compensatory  good.  The  diagnostic  skill 
of  the  surgeon  is  oftentimes  taxed  in  the  attempt  to  decide 
whether  the  patient  shall  be  consigned  to  the  category  of  the 
inoperable,  or  whether  further  surgical  measures  are  justified. 

When,  therefore,  the  surgeon  is  called  upon  to  treat  a  pa- 
tient who,  for  any  reason,  is  unmistakably  the  victim  of  inop- 
erable cancer,  the  question  may  justly  be  asked,  "What  more 
can  surgery  do  ?"  So  far  as  the  cancer  itself  is  concerned  the 
answer  must  undoubtedly  be,  "Nothing."    But  what  about  the 

'  Bainbridge,  W.  S. — ' '  Irremovable  Cancer, "  N.  Y.  Med.  Jour.,  October 
3,  1908. 

415 


416  THE   CANCER    PROBLEM 

patient  ?  Shall  we  fold  our  hands  and  say,  ''All  has  been  done 
that  can  be  done  by  surgical  means ;  opiates  and  other  pallia- 
tive measures  are  all  that  may  be  employed;  death  only  can 
bring  relief?"  Emphatically,  No!  Surgery  may  still  have  a 
purpose  to  fulfil. 

Cancer,  in  the  majority  of  cases,  is  not  an  acute  disease,  but 
one  which  kills  by  slow  and  often  painful  processes.  In  the 
class  of  cases  now  under  discussion,  relief  from  pain  may  be 
given  by  surgical  methods.  This  may  be  done  through  the  treat- 
ment of  indirect  conditions  caused  by  the  cancer. 

The  various  surgical  procedures  which  aim  solely  at  the  pro- 
longation of  life  and  the  amelioration  of  pain  and  other  symp- 
toms have  been  called  "emotional  surgery,"  and  those  who 
advocate  the  methods  have  been  pronounced  "emotional  sur- 
geons," Perhaps  the  allegation  is  correct ;  but  I  feel  sure  that 
only  those  who  are  afraid  of  increasing  the  number  of  death 
certificates,  or  those  who  are  callous  to  human  suffering,  will 
refuse  to  accord  to  these  unfortunate  patients  whatever  modi- 
cum of  relief  surgery  can  afi"ord. 

Year  by  year  more  is  being  accomplished,  by  both  surgical 
and  non-surgical  means,  for  the  victims  of  irremovable  cancer. 
In  addition  to  various  special  surgical  methods  (see  Section 
XI,  Chapter  2,  X-rays,  fulguration,  thermopenetration,  thermo- 
radiotherapy (see  Section  X,  Chapter  2),  and  numerous  other 
kinds  of  treatment  are  now  being  employed  for  the  relief  of  pa- 
tients who  have  formerly  been  consigned  to  the  fate  of  "the  usual 
palliative  measures" — cleansing  applications,  dressings,  opiates, 
etc. 

Among  many,  however,  there  is  still  a  tendency  to  move  in 
the  line  of  least  resistance,  and  to  resort  to  this  palliative  treat- 
ment where  more  radical  and  effective  measures  should  be  em- 
ployed. The  physician,  and  those  who  compose  the  most  im- 
mediate world  of  the  victim  of  advanced  cancer,  are  prone  to 
consider  the  case  incurable.  Looking  upon  such  an  individual 
as  a  "cancer  case,"  for  whom  little,  if  anything,  can  be  done, 
they  often  fail  to  realize  that  the  patient,  while  suffering  from 
cancer,  may  at  the  same  time  be  the  subject  of  any  one,  or  a 
combination,  of  other  ills. 

In  consequence  of  this  attitude,  when  anything  at  all  is  done, 
the  cancer,  rather  than  the  patient,  is  treated.  This  mental  atti- 
tude is  quickly  interpreted,  and  the  gloom  of  the  physician,  at- 
tendants, and  relatives  is  reflected  upon  the  patient,  giving  thus 
an  added  hopelessness  to  the  situation  and  hastening  the  ultimate 
outcome  of  the  disease. 

Let  us  advocate  a  humane  and  skilful  effort,  by  all  possible 


IRREMOVABLE   CANCER  417 

surgical  or  other  means,  to  relieve  the  concomitant  symptoms 
of  the  advanced  stages  of  cancer,  rather  than  he  content  M^ith 
the  "usual  palliative  measures."  Conservative  treatment,  in 
the  broadest  acceptation  of  the  term,  is  surely  the  adaptation  of 
the  measures  employed,  be  they  surgical,  electrical,  medical,  or 
what  not,  to  the  needs  of  the  individual.  This  of  necessity  in- 
volves, not  only  the  treatment  of  the  cancer  itself,  but  the 
correction,  v^hen  possible,  of  all  concurrent  pathological  con- 
ditions which  may  have  been  caused  by,  or  which  may  compli- 
cate, the  malignant  disease.  It  also  necessitates  careful  con- 
sideration as  to  whether  the  case  is  operable  or  inoperable. 

In  this  connection  it  may  be  interesting  to  note  the  classifica- 
tion of  "inoperable"  cancer  given  by  Morris  :^ 

"The  term  'inoperable'  means  that  the  disease  cannot  be 
entirely  eradicated,  or  permanent  immunity  hoped  for,  by  a 
cutting  operation,  or  by  actual  cautery,  or  any  escharotic  aiding 
the  knife.  It  does  not  imply  that  malignant  disease  is  of  con- 
stitutional as  distinct  from  local  origin,  and  that  as  such  it  is 
ineradicable.  On  the  contrary,  I  take  it  for  granted  that  can- 
cer is  at  first,  and  so  far  as  rodent  cancer  is  concerned,  through- 
out a  local  disease.  But  even  on  this  view  there  are  four 
groups  of  inoperable  cases.  They  are:  (1)  primary  cancer 
affecting  inaccessible  parts  and  organs;  (2)  primary  cancer 
which,  though  originating  in  an  accessible  part  or  organ  of  the 
body,  has  been  allowed  to  extend  beyond  the  limits  within 
which  an  operation  is  prudent  and  complete  removal  possible ; 
(3)  certain  cases  of  acute  diffiise  carcinoma  and  very  rapidly 
growing  or  widely  infiltrating  new  growths  of  exceptionally 
virulent  character;  and  (4)  recurrent  cancer,  where  the  disease 
has  recurred  in  multiple  metastatic  foci  or  in  parts  beyond  the 
limits  of  removal.  Many  of  the  cases  included  in  these  groups 
are  submitted  to  operation  for  the  purpose  of  palliating  symp- 
toms or  prolonging  life.  Hence  the  term  'treatment'  as  applied 
to  inoperable  cancer  means  one  of  two  things:  (1)  the  employ- 
ment of  remedies  and  methods  other  than  the  knife,  to  cure, 
ameliorate,  or  retard  the  disease,  as  well  as  to  prevent  relapses 
after  its  removal;  or  (2)  the  employment  of  the  knife  to  give 
relief  from  pain  and  to  prolong  life,  to  restore  function,  and 
otherwise  to  make  the  patient's  condition  more  tolerable." 

^  Morris,    Sir    Henry,    Bart. — * '  The    Treatment   of    Inoperable    Cancer, ' ' 
The  Lancet,  October  3,  1908. 


418  THE   CANCER    PROBLEM 


SEEMINGLY   IRREMOVABLE 

The  cancer  per  se  may  be  easily  amenable  to  operation,  while, 
for  various  reasons,  it  may  be  seemingly  irremovable.  In  such 
instances  it  may  perhaps  be  only  natural  to  place  the  patient 
in  the  category  of  the  inoperable,  and  eventually  the  incurable. 
A  careful  study  of  the  individual  case  often  reveals  the  fact 
that  it  belongs  to  neither  category,  for  the  following  reasons : 

(1)  The  patient's  condition  in  other  respects  may  render 
the  cancer  seemingly  irremovable.  If  the  contraindicative 
condition  is  temporary,  as  in  the  case  of  concurrent  acute  affec- 
tions, proper  measures  for  correction  should  be  instituted.  A 
cancer  which  is  seemingly  inoperable  and  irremovable  may  be 
rendered  both  operable  and  removable  by  proper  care  of  the 
patient. 

If  the  general  condition  of  the  patient,  from  whatever  cause, 
is  such  as  to  render  precarious  the  administration  of  a  general 
anesthetic,  with  the  shock  of  a  major  operation ;  and  if  local 
anesthesia  or  spinal  analgesia  are  impossible  or  inadvisable, 
time  must  be  given  to  the  general  upbuilding  of  strength  and 
bodily  resistance.  It  is  necessary  in  such  cases  to  exercise 
judgment  in  the  matter  of  how  long  operative  procedure  may  be 
delayed  without  menace  to  the  patient's  life  from  the  malignant 
growth.  It  may  at  times  be  the  part  of  wisdom  to  run  surgical 
risk  in  the  operable  stage  of  cancer,  complicated  by  other  con- 
ditions, rather  than  to  delay  too  long  and  allow  the  patient  to 
pass  into  the  irremovable,  even  though  operable,  stage. 

It  is  just  here  that  surgeons  may  often  err.  The  cancer 
obscures,  in  their  eyes,  all  other  conditions,  and  a  patient  who 
may  be  easily  amenable  to  operative  procedure  after  due  at- 
tention to  other  conditions,  is  pronounced  "incurable,"  "inop- 
erable," or  the  cancer,  "irremovable."  On  the  other  hand,  the 
patient  may  be  subjected  to  the  risk  of  operative  procedure  be- 
fore due  attention  is  given  to  the  concurrent  conditions,  life 
being  thus  unnecessarily  endangered.  The  ability  to  carry  the 
patient  safely  past  the  dangers  of  too  early  operation  on  the  one 
hand,  and  the  fatal  error  of  too  long-delayed  surgical  interven- 
tion on  the  other,  entails  a  certain  intuitive  sense,  which  comes 
only  through  large  personal  experience  in  the  treatment  of  ma- 
lignant disease,  and  which  cannot  be  fully  explained  or  im- 
parted to  others. 

(2)  Malignant  new  growths  are  sometimes  seemingly  ir- 
removable when  they  are  superimposed  upon  lupus  erythe- 
matosus, lupus  \T^ilgaris,  or  syphilis.     The  author  has  seen  a 


IRREMOVABLE   CANCER  419 

few  cases  of  cancer  of  the  breast,  complicated  by  uterine 
fibroids  causing  hemorrhage,  which  have  been  pronounced  irre- 
movable, the  supposition  being  carelessly  reached  that  the 
uterine  condition  is  cancerous  and  of  a  too  advanced  stage  to 
permit  of  operation. 

(3)  Concurrent  complications  in  the  neighborhood  of  the 
cancer  may  lead  to  the  simulation  and  diagnosis  of  an  irremov- 
able growth.  There  may  be  tissues  in  the  neighborhood  which 
are  involved  in  inflammatory  reaction ;  neighboring  glands  may 
be  the  seat  of  pus  collections;  and  various  other  complications 
may  for  a  time  obscure  the  prognosis  with  reference  to  the 
cancer.  Under  such  circumstances,  because  of  the  seeming 
hopelessness  of  the  condition,  both  the  complication  and  the 
malignant  disease  are  neglected  until  the  cancer  in  reality  be- 
comes hopeless. 

(4)  Septicemia  or  sapremia,  arising  from  causes  only  in- 
directly associated  with  the  cancer,  or  even  having  no  -relation 
to  it,  may  so  overwhelm  the  patient,  because  of  the  profound 
intoxication  of  the  system,  and  the  consequent  lowering  of 
resistance,  as  to  lead  to  the  belief  that  the  cancer  is  irremov- 
able. Removal  of  the  cause  and  the  promotion  of  elimination 
will  in  some  cases  so  completely  overcome  the  complicating 
condition  as  to  render  the  cancer  easily  operable. 

(5)  Cases  are  sometimes  consigned  to  the  inoperable  and 
irremovable  class  because  the  risk  from  operative  procedure 
seems  too  great  to  be  incurred.  This  conclusion  may  be  based 
upon  the  extent  of  the  involvement,  or  upon  the  patient's  low- 
ered vitality  and  lessened  resistance.  In  many  instances  the 
risk  undoubtedly  is  too  great  to  warrant  operative  procedure, 
but  the  surgeon  should  not  be  too  easily  discouraged  by  either 
the  extent  of  the  involvement  or  the  unfavorable  condition  of 
the  patient.  It  is  possible  in  many  instances,  by  what  has  been 
called  ^'appallingly  radical  surgery,"  to  literally  cheat  the 
grave  of  its  prey  for  many  months  and  even  for  years. 

(6)  Another  factor  which  may  lead  to  the  verdict  "irre- 
movable" is  an  unqualified  mistake  in  diagnosis.  An  extensive 
gummatous  involvement  of  the  tongue,  for  example,  has  been 
mistaken  for  cancer,  and,  even  after  removal  of  the  tongue,  an 
unfavorable  prognosis  as  to  cure  has  been  rendered.  Such  a 
mistake,  with  our  present  methods  of  diagnosis,  is  mentioned 
merely  because,  inexcusable  as  it  is,  it  does  occur.  (See  Sec* 
tion  VII,  Chapter  III,  p.  200.) 


420  THE   CANCER    PROBLEM 

OPERABLE   BUT   IRREMOVABLE,    YET   CURABLE 

Strictly  speaking,  cancer  is  "curable"  only  in  so  far  as  it  is 
removable,  inasmuch  as  we  possess  no  known  agency  by  which 
we  are  able  definitely  to  cure  the  disease  when  left  in  situ.  In 
effect,  we  are  justified  in  saying  we  cure  a  cancer  which  is 
subjected  to  early  and  complete  removal,  as  judged  by  a  rea- 
sonable period  of  non-recurrence.  There  are  other  circum- 
stances, however,  under  which  it  may  be  said  that  cancer  is 
cured,  or  indefinitely  held  in  abeyance,  and  to  some  of  these 
attention  is  now  directed.  Spontaneous  retrogression  or  "cure" 
is  not  under  discussion  here.  This  subject  is  considered  else- 
where. (See  Section  VI,  p.  172,  and  Section  VII,  Chapter  1, 
p.  186.) 

A  limited  number  of  cases  of  advanced  cancer  have  been 
cured,  or  at  least  held  in  abeyance  for  a  number  of  years,  by 
removing  as  much  as  possible  of  an  irremovable  growth  and  in- 
stituting other  measures,  by  the  aid  of  which  nature  seems  able 
to  cope  with  the  malignant  process,  holding  it  in  check  so  com- 
pletely that  the  disease  may  be  said  to  have  been  cured. 

Such  an  instance  is  Case  ^o.  I  of  the  series  reported  by 
Dawbarn.^  The  operation  of  carotid  excision  was  performed 
on  June  1,  1895.  On  going  to  press,  March,  1903,  eight  years 
later,  the  patient  was  perfectly  well,  and  when  last  heard  from, 
in  1907,  was  still  in  perfect  health.  The  condition  for  which 
the  operation  was  performed  was  round-celled  sarcoma  involv- 
ing the  nasopharynx,  filling  both  nares,  rendering  deglutition 
and  respiration  difficult,  and  interfering  with  articulation. 
The  growth  caused  severe  headache  and  dizziness.  When  a 
case  of  this  character  is  reported  as  well  twelve  years  after 
operation  it  is  reasonable  to  say  that  a  cure  was  effected,  de- 
spite the  fact  that  the  cancer  was  irremovable. 

Sometimes  partial  removal  of  diseased  tissue  results  in  ces- 
sation of  growth  and  apparent  cure.  An  illustrative  case  in 
the  author's  experience  is  that  of  melanotic  sarcoma  on  the 
wrist  of  a  man,  with  extension  into  the  axilla  and  upward  to 
the  clavicle,  filling  Mohrenheim's  space  above,  and  completely 
surrounding  the  subclavian  vein  to  its  entrance  into  the  chest. 
The  tumor  on  the  wrist  was  excised,  and  the  axilla  cleared  out, 
but  it  was  impossible  to  remove  all  the  diseased  tissue.  The 
outer  surface  of  the  ribs  was  scraped,  and  the  external  inter- 
costals,  which  were  diseased,  were  curetted  for  some  distance. 
The  operation  was  performed  in  December,  1902,  and  in  Janu- 

'  Dawbarn,  Robert  H.  M. — ' '  Starvation  Treatment  of  Malignant  Growths 

by  Excision  of  the  External  Carotids,"  1903,  p.  9. 


IRREMOVABLE   CANCER  421 

ary,  1914,  the  patient  was  perfectly  well,  with  free  use  of  his 
arm.     ISTo  other  form  of  treatment  was  employed  in  this  case. 


OPERABLE,    BUT    IRREMOVABLE    AND    INCURABLE 

A  large  proportion  of  cases  of  advanced  cancer  come  under 
this  category.  It  may  be  impossible  to  remove  all  the  diseased 
tissue,  yet  the  case  may  be  amenable  to  a  variety  of  surgical 
procedures  for  the  relief  of  pain  and  prolongation  of  life. 

The  management  of  these  cases  may  be  considered  under  the 
following  heads:  (1)  treatment  of  indirect  conditions  caused 
by  or  complicating  the  cancer;  (2)  treatment  of  the  cancer  per 
se;  (3)  treatment  of  the  patient. 

Treatment  of  Conditions  Caused  by  or  Complicating  the  Cancer. 
— A  malignant  tumor  may  give  rise  to  various  conditions 
which  call  for  relief  by  surgical  interference  quite  apart'  from 
that  which  involves  the  cancer.  It  may,  for  example,  cause 
obstruction  of  the  nose,  of  the  esophagus,  of  the  stomach,  or  of 
any  portion  of  the  intestinal  tract,  necessitating,  as  the  case 
may  be,  tracheotomy,  esophagostomy,  gastrostomy,  enteroenter- 
ostomy,  colostomy,  short-circuiting,  etc.  In  cases  of  obstruc- 
tion of  the  bladder,  suprapubic  cystostomy  or  perineal  drainage 
may  be  necessary.  An  irremovable  tumor  in  the  axilla,  either 
a  primary  growth  or,  more  frequently,  a  recurrence  following 
mammary  cancer,  may,  by  pressure  upon  the  lymph  vessels, 
cause  marked  and  painful  swelling  of  the  arm,  the  resulting 
condition  being  sometimes  known  as  "brawny  arm,"  or  "big 
arm,"  which  may  be  relieved  by  lymphangioplasty.  Paracen- 
tesis of  the  pleura  in  cancer  of  the  lung  and  pleura,  and  of  the 
abdomen  in  certain  cases  involving  the  abdominal  viscera,  and 
decompression  operations  in  cases  of  cerebral  tumor,  relieve 
pressure  and  other  concomitant  symptoms.  The  malignant 
growth  may  press  upon  nerves,  giving  rise  to  the  most  excruciat- 
ing pain.  When  it  is  possible  to  reach  and  cut  the  nerves  thus 
pressed  upon,  great  relief  may  be  obtained.  Pressure  symptoms 
may  be  relieved  by  arterial  ligation  with  lymphatic  block. 

It  is  impracticable  in  this  connection  to  call  attention  to  all 
the  possible  complications  which  may  be  encountered  in  the 
treatment  of  advanced  cancer.  The  surgeon  must  be  able  to 
recognize  them  as  they  arise,  and  to  cope  with  them  in  the 
most  advantageous  manner.  Above  all,  he  should  not  fall  into 
the  error  of  neglecting  remediable  conditions  merely  because 
they  complicate  advanced  cancer.     The  special  technic  of  the 


422  THE   CANCER   PROBLEM 

most  important  palliative  procedures  is  given  in  Section  XI, 
Chapter  2. 

Treatment  of  the  Cancer  Per  Se. — Various  methods  have  been 
employed  in  the  attempt  to  arrest  the  growth  of  the  cancer  and 
to  alleviate  the  symptoms  which  are  the  direct  outcome  of  the 
disease.  Many  agents  and  methods  which  have  been  employed 
with  the  hope  of  effecting  a  cure  have  been  found  to  do  no  more 
than  serve  as  palliative  measures,  while  many  others  have  been 
used  solely  with  the  latter  object  in  view.  Certain  methods 
are  applicable  only  in  cases  of  irremovable  cancer  of  certain 
localities.  Notable  instances  are  l^onphangioplasty  in  "brawny 
arm/'  arterial  ligation  for  advanced  cancer  of  the  neck  and 
face  and  of  the  pelvic  organs,  and  thermoradiotherapy  in  can- 
cer of  various  regions.  Aside  from  such  indirect  measures, 
nothing  remains  to  be  done,  so  far  as  the  cancer  itself  is  con- 
cerned, except  to  keep  the  fungating  or  raw  surfaces  clean,  to 
lessen  fetor  and  discharge,  and  to  prevent  irritation. 

Treatment  of  Patient — In  addition  to  the  proper  recognition 
of,  and  attention  to,  concurrent  affections,  acute  or  chronic, 
which  may  complicate  malignant  disease  in  the  advanced 
stages,  and  to  the  requisite  treatment  of  the  cancer  per  se,  it  is 
important  to  treat  the  patient. 

It  is  of  the  greatest  moment  to  the  mental  and  physical  com- 
fort of  the  patient  that  the  hygienic  conditions,  both  of  the 
body  and  of  the  external  surroundings,  be  the  best  possible.  A 
varied  dietar}^  of  wholesome  and  appetizing  food,  an  abun- 
dance of  fresh  air  and  sunshine,  and  a  sympathetic  and  cheerful 
attitude  on  the  part  of  nurses  and  other  attendants,  will  ma- 
terially assist  in  the  fight  for  life. 

It  is  necessary  to  combat  the  evil  effects  of  the  cancerous 
process  upon  the  system  by  the  administration  of  tonics,  di- 
gestives, and  such  measures  as  may  be  necessary  to  facilitate 
elimination.  It  is  of  the  utmost  importance  that  the  emunctory 
organs  be  kept  active.  In  many  instances  the  patient  is  cachectic 
as  much  or  more  from  the  locking  up  of  the  secretions  by 
physical  inactivity,  by  insufficient  or  improper  food,  and  by 
morphia,  as  by  the  disease  itself. 


INOPERABLE,   IRREMOVABLE,   INCURABLE 

When  surgical  procedure  offers  no  further  hope  of  relief, 
when  the  various  medicinal  agents  have  failed  to  check  the 
ravages  of  the  disease,  when  electrotherapy,  radiotherapy, 
serumtherapy,  and  the  various  other  methods  have  been  tried 


IRREMOVABLE   CANCER  423 

and  found  wanting,  what  then  ?  The  patient  is  now  surely 
inoperable,  and  the  cancer  is  irremovable  and  incurable?  The 
sole  aim  of  treatment  is  now  the  alleviation  of  the  suffering 
of  the  patient  and  of  the  discomfort  of  those  about  the  unfortu- 
nate one.  It  is  well  known  that  many  of  these  sufferers  live  for 
years  with  what  the  laity  call  "eating  cancer" ;  these  years,  or 
whatever  length  of  days  remains,  should  be  made  as  comfortable 
as  possible.  IvTow,  as  much  as  ever,  the  patient  should  be 
treated. 

Institutional  Care. — When  the  patient  has  reached  the  final 
stage  of  cancer,  unless  he  is  the  fortunate  possessor  of  sufficient 
means  to  procure  the  equivalent  of  hospital  service,  institutional 
care  may  be  necessary.  It  is  too  much  to  expect  the  average 
family  to  devote  the  requisite  attention  to  such  patients,  but 
hitherto  it  has  been  impossible  for  the  humane  part  of  the  com- 
munity to  provide  proper  care  for  more  than  a  minute  propor- 
tion of  this  most  unfortunate  class.  By  reference  to  the  section 
which  deals  with  hospitals  and  other  institutions  for  the  care  of 
cancer  patients  (Section  XIII)  it  will  be  seen  how  inadequate 
even  yet  is  such  provision  throughout  the  civilized  world. 

Mental  Condition. — However  hopeless  the  physician  and  at- 
tendants may  be  regarding  the  outcome  of  a  given  case,  the 
patient  is  often  hopeful.  By  nurturing  this  spark  of  courage  the 
remaining  span  of  life  may  be  rendered  more  bearable  for  the 
unfortunate  victim.  Even  when  the  patient  shares  the  general 
gloom,  and,  as  is  sometimes  the  case,  begs  to  have  the  end 
hastened,  the  physician  is  not  allowed  by  ethics  or  law  to  resort 
to  euthenasia.  In  such  cases  great  mental  relief  comes  with 
the  realization  that  those  in  attendance  manifest  a  willingness 
to  do  everything  possible  for  the  comfort  and  welfare  of  the 
sufferer.  In  many  instances,  in  institutions,  the  patient's  men- 
tal condition  is  improved,  and  likewise  the  physical  well-being, 
by  the  regime,  and  by  the  consciousness  that  the  loved  ones  at 
home  are  relieved  of  responsibility  and  care. 

The  following  cases,  recently  under  my  charge,  are  cited  to 
show  how  the  exercise  of  consideration  in  the  care  of  patients 
suffering  from  advanced  cancer  may  relieve  suffering  and  ap- 
parently prolong  life,  and  how,  in  some  instances,  when  hope 
is  ruthlessly  snatched  away,  the  end  may  be  hastened. 

Four  patients,  in  the  same  ward,  were  suffering  from  ad- 
vanced cancer.  The  first  was  cancer  of  the  breast.  This  pa- 
tient had  had  recourse  to  "faith  cure,"  and  later  had  been 
treated  with  X-rays.  Upon  admission  to  the  hospital  there  was 
an  immense  ulcerating  cancer  below  the  right  shoulder  and 
back  of  the  axilla,  the  fetid  mass  extending  over  the  right 


424  THE   CANCER    PROBLEM 

chest.  The  arm  was  enormously  swollen.  No  surgery,  not 
even  lymphangioplasty,  had  been  employed.  The  surfaces  were 
cleansed  with  yeast  and  later  treated  by  thermic  coagulation. 
After  eight  months  the  patient  was  much  better  than  when  the 
treatment  was  begun.  The  cancer  was  not  cured,  but  the  mixed 
infection  was  controlled.  The  woman  was  not  promised  a  cure, 
but  was  assured  that  she  could  be  helped. 

Ill  the  next  bed  was  a  woman  who  was  brought  in  on  a 
stretcher,  practically  bleeding  to  death  from  far  advanced  pel- 
vic cancer.  The  ^^starvation  ligature"  was  employed,  and  in 
a  few  weeks  the  patient  was  up  and  about  the  ward.  The 
fetid  discharge  was  checked,  the  hemorrhage  was  controlled, 
and  the  pain  was  greatly  mitigated.  Six  months  after  leaving 
the  hospital  she  was  going  regularly  for  treatment  by  means 
of  thermoradiotherapy,  was  living  in  comparative  comfort,  and 
still  hopeful. 

In  the  third  bed  was  a  woman  who  was  suffering  from  ad- 
vanced cancer  of  the  ovary,  involving  the  pelvis,  irremovable, 
and  complicated  by  intestinal  obstruction.  Laparotomy  was 
performed  and  the  intestinal  obstruction  relieved.  The  cancer 
was  not  cured,  but  the  patient  was  discharged  greatly  improved, 
and  was  going  regularly  for  thermoradiotherapy  three  months 
after  the  operation. 

In  the  fourth  bed  was  a  young  woman,  the  mother  of  two 
children,  w4io  had  been  brought  into  the  hospital  on  a  stretcher 
in  a  pitiable  condition,  suffering  with  cancer  of  both  breasts. 
Examination  revealed  that,  while  the  cancer  of  the  breasts 
might  have  been  operated  upon,  the  case  was  complicated  by  an 
extensive  cancer  of  the  left  lung.  After  a  few  treatments  with 
thermoradiotherapy  she  was  able  to  be  up  and  about  the  ward, 
breathing  much  improved,  pain  and  discharge  greatly  lessened. 
The  family  insisted  that  she  should  know  her  true  condition. 
On  Tuesday  she  was  told  the  exact  facts,  at  once  lost  all  hope, 
and  was  buried  on  the  following  Sunday. 

The  above  observations  are  not  in  keeping  with  the  experi- 
ence of  all  surgeons.  Sir  Alfred  Pearce-Gould,^  for  example, 
whose  experience  covers  thirty  years  on  the  surgical  staff  of  the 
Middlesex  Hospital,  London,  says: 

"The  mental  quietude  the  patients  usually  exhibit  is  quite 
striking,  and  I  believe  it  has  important  physical  effects.  In 
its  absence  we  usually  find  ourselves  unable  to  relieve  these 
patients  as  we  are  accustomed  to  do.  I  have  often  heard  from 
the  sister  of  the  ward  that  'No,  so-and-so  has  not  settled  down 

1  Gould,  Sir  Alfred  Pearce-. — "The  Treatment  of  Inoperable  Cancer," 
The  Lancet,  January  25,  1913,  p.  216. 


IRREMOVABLE   CANCER  425 

yet/  and  this  is  given  as  the  explanation  of  physical  ills.  This 
'settling  down'  is  an  important  condition  of  physical  well-being 
in  these  poor  sufferers ;  it  means  more  than  getting  accustomed 
to  new  and  strange  surroundings,  to  the  getting  over  the  sepa- 
ration from  'home' — a  word  that  is  as  sacred  and  as  full  of 
meaning  upon  the  lips  of  a  poor  hospital  patient  as  from  any- 
one. It  means  the  absence  of  anxiety  about  husband  or  wife 
and  children,  the  confidence  that  one's  own  wants  will  be  met 
even  to  the  end,  and  I  have  come  to  think  that  the  knowledge 
of  the  incurable  nature  of  their  illness  is  also,  as  a  rule,  not 
without  its  helpful  influence.  Here,  I  know,  I  am  making  a 
statement  that  will  not  win  general  acceptance.  I  am  very 
often  requested  by  the  friends  of  patients  not  to  let  them  know 
that  they  are  suffering  from  cancer,  and  such  a  request  one  is 
bound  to  respect.  But,  all  the  same,  I  must  say  that  in  my 
experience  the  knowledge  of  the  real  state  of  affairs  has  very 
rarely  seemed  to  do  harm,  and  in  the  late  stage  of  the  disease, 
when  curative  measures  are  not  to  be  thought  of,  and  palliation 
is  our  function,  it  has  seemed  to  do  great  good." 

In  this  matter,  as  in  all  others,  the  patient  must  be  treated, 
mentally  as  well  as  physically,  according  to  individual  need. 
My  own  experience  has  convinced  me  that  in  a  large  proportion 
of  cases  of  advanced  cancer,  particularly  of  the  abdominal  and 
pelvic  organs,  even  when  this  is  secondary  to  external  cancer 
which  has  been  removed,  it  is  possible  to  conceal,  in  part,  the 
real  state  of  affairs  from  the  patient,  and  thus  to  obviate,  in  a 
measure,  the  mental  suffering  and  anxiety  which  would  other- 
wise attend  the  last  days  of  life. 

It  has  been  observed  by  physicians  and  nurses  in  charge  of 
wards  for  incurable  cancer  that  much  of  the  mental  and  physi- 
cal discomfort  of  these  patients  during  the  first  few  days  after 
admission  is  the  result  of  breaking  them  of  the  morphin  habit. 
During  this  period  of  "settling  down"  aspirin,  salol,  and  simi- 
lar agents  are  most  helpful.  After  a  few  days  the  patient 
gradually  ceases  to  depend  upon  or  to  expect  morphin,  and  the 
miiid  then  becomes  more  at  rest.  The  general  physical  im- 
provement which  so  often  follows  the  more  or  less  complete 
elimination  of  morphin,  reacts  favorably  upon  the  mental  con- 
dition, this,  in  turn,  upon  the  physical,  and  thus  the  patient  is 
often  enabled  to  live  through  the  remaining  time  of  life  in 
relative  peace  and  comfort. 

Physical  Condition. — As  the  malignant  disease  makes  ever 
increasing  inroads  upon  the  vitality  of  its  victim,  there  is  more 
and  more  need  for  attention  to  the  general  physical  condition. 
The  emunctory  organs  must  be  kept  active  by  the  regulation 


426  THE   CANCER   PROBLEM 

of  the  diet  to  suit  the  needs  of  the  individual,  and  by  the  ad- 
ministration of  the  necessary  tonics,  digestives  and  medication 
which  facilitates  the  eliminative  processes  of  the  body.  This 
is  particularly  important  in  patients  who  are  markedly  cachec- 
tic, and  in  those  to  whom  morphin  is  given  for  the  alleviation 
of  pain.  Attention  has  already  been  called  to  the  fact  that  the 
patient  is  often  cachectic  as  much  or  more  from  the  locking  up 
of  the  secretions  by  physical  inactivity,  by  insufficient  or  im- 
proper food,  and  by  the  continued  administration  of  morphin, 
as  from  the  effects  of  the  disease  itself.  This  is  particularly 
true  in  the  last  stages.  Physical  fatigue  and  mental  unrest  add 
to  this  difficulty.  Constipation  is  especially  to  be  noted  and 
obviated.  In  uterine  cancer  discomfort  is  very  greatly  in- 
creased by  the  pressure  from  a  lower  bowel  packed  with  fecal 
matter.  Drastic  purges  should  not  be  given,  particularly  in 
involvement  of  the  bowel.  As  a  rule,  mild  aperients  and  bland 
enemata  will  answer  the  purpose.  If  not,  attention  must  be 
more  closely  directed  toward  the  diet  and  general  hygienic 
surroundings. 

The  general  physical  well-being  of  the  victim  of  advanced 
cancer  is  improved  by  an  abundance  of  fresh  air  and  sunshine. 
How  often  is  the  poor  sufferer  confined  in  a  small,  dark,  poorly 
ventilated  room,  where  he  is  almost  literally  suffocated  by  the 
foul  air  which  his  own  disease  has  vitiated ! 

Diet. — A  great  deal  has  been  written  with  reference  to  the 
influence  of  diet  in  the  production  of  cancer  and  in  the  stimula- 
tion of  the  process  once  it  has  been  initiated.  Too  much  of  this 
or  too  little  of  that  constituent,  certain  articles  of  food,  over- 
indulgence in  food  in  general — these  and  many  other  ideas  with 
reference  to  the  effect  of  diet  on  cancer  have  been  proposed 
as  having  greater  or  less  significance.  Whatever  importance 
may  be  attached  to  diet  in  relation  to  the  cause  of  cancer — 
and  none  has  been  established, — such  significance  cannot  apply 
when  the  disease  has  reached  the  inoperable,  irremovable,  and 
incurable  stage.  It  is  to  be  considered  now  merely  from  the 
point  of  view  of  maintaining  strength,  of  aiding  elimination, 
and  of  stimulating  appetite.  In  order  to  accomplish  these  pur- 
poses the  diet  should  be  wholesome  and  varied.  ISTo  particular 
article  of  food  or  drink  need  necessarily  be  omitted,  and  no 
particular  constituent  of  any  article  of  food,  given  in  modera- 
tion, may  be  said  to  be  harmful.  Salt,  for  example,  has  been 
condemned  by  some,  notably  by  Beard  in  connection  with  the 
enzyme  treatment.  If,  however,  it  were  known  to  exert  a 
deleterious  influence  upon  the  course  of  the  disease  in  the  early 
stages — which  has  not  been  proved, — in  the  advanced  stages. 


IRREMOVABLE  CANCER  427 

when  the  appetite  is  none  too  good,  the  elimination  of  any  such 
effect  would  be  more  than  counterbalanced  by  the  insipidity  of 
a  salt-free  diet. 

Many  have  condemned  as  positively  harmful  the  use  of 
alcoholic  beverages  in  any  stage  of  cancer.  Gould/  for  example, 
holds  that  alcoholic  stimulants  of  all  kinds  are,  as  a  rule,  to  be 
avoided,  and  that  the  free  use  of  alcohol  adds  greatly  to  the 
activity  of  the  disease.  My  own  experience  is  that  it  may  be 
taken  in  moderation,  with  the  food,  serving  merely  as  an  ap- 
petizer. There  is  almost  invariably  a  tendency  to  hyperacidity 
in  these  cases,  hence  alkalies  and  alkaline  waters  should  be  given. 
Intestinal  antiseptics  and  antacids  are  helpful.  If  the  hyper- 
acidity is  unusually  pronounced,  the  diet  may  be  modified  ac- 
cordingly. 

Pain. — Pain  may  be  controlled  to  a  certain  extent  by  mor- 
phin,  to  be  counterbalanced  always  by  something  to  offset  its 
untoward  effects.  If  there  is  sweating,  atropin  may  be  given 
with  the  morphin,  or,  if  it  is  to  be  given  over  long  periods  of 
time,  it  may  be  administered  in  the  form  of  the  United  States 
or  the  British  solution,  with  the  elixir  of  lactopeptin.  Phen- 
acetin,  10  to  15  grains  twice  daily,  will  sometimes  be  sufficient 
to  control  severe  pain  and  to  make  the  patient  fairly  comfor- 
table. Aspirin,  salol,  antipyrin,  and  acetanilid  may  also  be 
used.  The  depressing  effects  of  the  coal  tar  products  should 
be  modified  by  stimulants. 

Care  of  Ulcerating  Surfaces  and  Fungating  Masses — Bearing 
in  mind  the  fact  that  the  discharges  from  broken-down  cancer 
are  often  rendered  more  offensive  by  the  action  of  putrefactive 
or  pyogenic  organisms,  attention  should  be  directed  to  keeping 
the  surfaces  clean  by  the  use  of  the  various  antiseptic  ointments 
and  washes.  Deodorizers,  ozone,  incense,  etc.,  may  be  used  in 
the  room  to  render  the  atmosphere  less  disagreeable. 

Fungating  masses  should  be  kept  clean  by  frequent  dressing. 
The  galvanocautery,  thermocoagulation,  zinc  chlorid  paste, 
lotio  pancreatis,  yeast  poultices,  and  various  other  local  appli- 
cations will  help  to  keep  the  surfaces  clean  and  to  lessen  fetor. 
Acetone,  peroxid  of  hydrogen,  permanganate  of  potassium,  and 
sanitas  are  useful  for  this  purpose.  It  must  not  be  forgotten, 
however,  that  local  applications,  particularly  pastes,  may  tend 
to  erode  blood  vessels  and  thus  give  rise  to  severe  and  perhaps 
fatal  hemorrhage.  Where  the  cancer  has  eaten  its  way  through 
the  tissues,  leaving  openings,  as  in  the  pharynx  or  base  of  the 
mouth,   the  compound  tincture  of  benzoin  with  nosophen  or 

1  Gould,  Sir  Alfred  Pearce-. — Loc.   cit. 

See  also:     "The  Bradshaw  Lecture  on  Cancer,"   1910,  p.  53. 


428  THE   CANCER    PROBLEM 

aristol  (Bainbridge's  modification  of  Whitehead's  shellac^) 
may  be  used  to  phig  the  openings.  This  tends  to  hold  the  parts 
in  position  and  makes  a  very  good  antiseptic  dressing.  Adrena- 
lin chlorid  is  also  useful  for  the  control  of  hemorrhage.  Ter- 
chlorid  of  antimony  will  help  to  check  hemorrhage  and  to  lessen 
fetor  in  uterine  cancer  after  the  vessels  have  been  ligated  and 
as  much  as  possible  of  the  diseased  tissue  removed. 

In  uterine  cancer  sloughing  or  fungating  masses  should  be 
removed  by  means  of  the  curet,  care  being  taken  not  to  in- 
jure the  peritoneum,  bladder,  ureter,  o;*  rectum,  which,  in  the 
presence  of  extensive  involvement,  may  be  easily  penetrated. 
Non-irritating  antiseptic  douches  should  be  employed  fre- 
quently. Where  there  is  danger  of  hemorrhage  it  is  well  to 
have  the  fluid  hot.  In  cancer  of  the  rectum  it  is  especially  im- 
portant that  cleanliness  be  maintained  by  the  removal,  by  means 
of  douches,  of  particles  of  fecal  matter  and  discharge. 

In  cancer  of  the  mouth  particular  attention  should  be  given 
to  cleanliness,  not  only  for  the  purpose  of  rendering  the  patient 
more  comfortable  and  of  lessening  fetor,  but  in  order  to  pre- 
vent the  swallowing,  with  the  food  or  saliva,  of  quantities  of 
cancerous  material  and  the  products  of  mixed  infection.  The 
frequent  use  of  mild  mouth  washes,  particularly  before  and 
after  meals,  the  removal,  by  means  of  pledgets  of  cotton,  of 
particles  of  food,  mucus,  or  discharge,  the  extraction  of  loose 
or  decayed  teeth  and  sequestra,  and  the  removal  of  sloughs,  will 
add  greatly  to  the  patient's  comfort. 

SUMUARY 

It  is  impossible  here — and,  indeed,  it  is  unnecessary — to 
attempt  an  enumeration  of  the  many  attentions  which  it  is 
possible,  feasible,  and  humane,  to  bestow  upon  the  victim  of 
inoperable,  irremovable,  and  incurable  cancer.  The  conscien- 
tious physician  and  nurse  will  recognize  and  endeavor  to  supply 
the  needs  of  each  individual. 

Irremovable  cancer  is  a  difficult,  and  many  times  a  discour- 
aging, condition  with  which  to  deal,  and  this  particular  field  is 
not  very  alluring  to  the  surgeon  who  is  trying  to  keep  down 
his  mortality  records  and  to  swell  the  list  of  his  surgical  suc- 
cesses. But  the  physician  or  surgeon  who  fails  to  do  the  very 
utmost  for  such  patients,  or  who  does  not  refer  them  to  those 
who  will  give  them  proper  attention,  is  not  true  to  the  spirit  of 
the  Hippocratic  oath. 

^  This  consists  of  twice  the  strength  of  compound  tincture  of  benzoin, 
with  nosophen  or  aristol  instead  of  iodoform. 


SECTION   XIII 

INSTITUTIONS  FOR  THE  CARE  OF  CANCER 
PATIENTS 

The  care  of  the  cancer  patient  is  a  problem  which  should  be 
considered  apart  from  the  investigation  of  the  disease. 

In  view  of  the  fact  that  perhaps  the  majority  of  the  general 
hospitals  throughout  the  world  receive  for  operation  only  those 
cases  of  cancer  ordinarily  classed  as  ''operable,"  we  have  in- 
cluded in  this  discussion  only  those  hospitals  and  "homes" 
which  care  for  so-called  "incurable"  cases.  "Quack"  institu- 
tions, of  course,  are  not  considered. 

No  attempt  is  made  to  give  a  complete  catalogue  of  institu- 
tions which  open  their  doors  to  the  victims  of  incurable  cancer. 
The  purpose  of  this  section  is  rather  to  emphasize  the  need  of 
larger  and  better  facilities  than  now  exist  for  the  care  of  this 
class  of  patients. 

Peculiar  needs  for  treatment,  care,  and  encouragement  mark 
the  life  of  the  incurable  cancer  patient.  Wealth  can  supply 
these  needs,  but  what  does  poverty  face  in  this  regard  ?  What 
possibilities  are  open  to  the  poor  for  the  proper  care  of  those 
so  afflicted? 

With  a  view  to  answering  the  above  questions,  the  Research 
Department  of  the  New  York  Skin  and  Cancer  Hospital  under- 
took a  fairly  comprehensive  canvass  of  the  institutions  of  New 
York  City  and  vicinity  two  years  ago.  The  results  of  this  in- 
vestigation, together  with  similar  data  concerning  certain  Euro- 
pean cities,  are  given  below. 


IN  EUROPE 

In  Europe  the  past  half  century  has  witnessed  an  enormous 
increase  in  the  number  of  general  hospitals,  and  in  the  number 
of  beds  in  the  older  hospitals.  There  has  been  also  a  great 
increase  in  the  number  of  surgical  operations,  many  of  which 
have  been  made  possible  by  anesthetics  and  asepsis.  This  ap- 
plies especially  to  cancer.    In  order  to  discover,  and  if  possible 

429 


430  THE   CANCER    PROBLEM 

to  remove  tumors,  surgery  has  gradually  progressed  to  every 
organ  of  the  body,  even  to  the  brain  and  spinal  cord.  On  look- 
ing back  over  this  development  of  hospitals  and  surgery,  one 
would  expect  to  find  a  corresponding  increase  in  the  amount 
of  special  provision  for  cancer  patients ;  it  is  astonishing,  there- 
fore, to  note  that  this  is  not  the  case. 

Great  Britain. — In  England  two  of  the  institutions  which 
provide  especially  for  cancer  patients  antedate  the  modern 
development  of  surgery,  and  only  three  have  been  added.  No 
doubt  this  is  largely  due  to  the  increased  provision  for  the 
treatment  of  this  disease  in  general  hospitals,  and  in  hospitals 
for  diseases  of  women.  Very  little  provision  is  made,  however, 
for  those  actually  dying  of  cancer.  Some  of  the  poor  obtain 
admission  to  workhouse  infirmaries  or  other  poor-law  institu- 
tions, and  the  more  fortunate  obtain  admission  to  some  "Hos- 
pice," "Home  for  the  Dying,"  or  "Home  for  Incurables."  Not- 
withstanding the  fatal  significance  of  these  names,  the  merciful 
provision  of  some  care  and  comfort  for  those  dying  of  cancer 
must  indeed  seem  a  blessing  to  those  who  can  obtain  any  kind 
of  hospital  attention  while  awaiting  the  inevitable  end.  The 
majority  of  those  who  succumb  to  cancer,  however,  die  outside 
hospitals,  in  their  own  homes,  or  in  those  of  relatives. 

Why  is  this  state  of  affairs  tolerated?  The  answer  is  that 
there  has  arisen  no  need  for  segregation,  as  in  epidemic  dis- 
eases, no  evil  effects  having  been  produced  upon  the  community 
by  allowing  cancer  patients  and  those  dying  of  cancer  to  mix 
freely  with  the  rest  of  the  population.  If  there  are  from  40,000 
to  50,000  deaths  from  cancer  in  a  year  in  the  United  States, 
then  there  are  from  120,000  to  150,000  living  who  are  suffering 
from  the  disease,  all  the  year  round.  There  is  no  means  of  esti- 
mating in  this  country  what  proportion  receives  hospital  treat- 
ment or  dies  in  institutions.  Only  for  England  are  such  figvires 
available.  In  that  country  of  15,589  males  and  20,313  fe- 
males dying  of  cancer,  4,618,  or  30  per  cent,  of  males,  and 
3,971,  or  20  per  cent,  of  females,  died  in  institutions.  In  Lon- 
don the  proportions  so  dying  are  higher  than  in  the  country 
towns,  smaller  cities,  and  rural  districts. 

The  institutions  devoted  solely  to  the  treatment  of  cancer 
in  England  are  only  five  in  number,  providing  a  total  of  only 
200  beds,  very  few  of  these  being  set  aside  for  patients  remain- 
ing an  unlimited  time,  or  "until  relieved  by  art  or  released  by 
death,"  as  in  the  case  of  special  wards  of  the  Middlesex  Hos- 
pital, the  pioneer  institution  of  this  kind.  The  Cancer  Charity 
of  the  Middlesex  Hospital,  London,  was  founded  in  1792, 
underwent  extension  in  1900  when  a  new  wing  was  added, 


INSTITUTIONS    FOR    CANCER    PATIENTS        431 

and  extension  again  three  years  ago  when  a  new  block  was 
built  in  memory  of  Mr.  Barnato.  (See  Section  I.)  There  is 
accommodation  for  40  patients,  and  out-patients  are  also  re- 
ceived. The  Cancer  Hospital,  Brompton,  London,  was  founded 
in  1851,  and  now  contains  102  beds,  only  a  few  of  which 
are  set  aside  for  incurable  cases.  In  Manchester  there  is  a 
Cancer  Pavilion  and  Home  attached  to  the  Christie  Hospi- 
tal, It  was  established  in  1892,  and  contains  30  beds.  The 
Royal  Cancer  Hospital,  Glasgow,  founded  in  1890,  and  con- 
taining 40  beds,  completes  the  list  for  Great  Britain.  For  a 
time  there  was  some  special  provision  for  cancer  patients  in 
the  Infirmaries  of  Dundee  and  Liverpool,  but  the  grants  having 
been  of  only  a  temporary  nature,  this  has  now  ceased. 

The  Continent. — On  the  Continent  provisions  of  the  above 
character  are  even  less  satisfactory  than  in  Great  JBritain. 
There  is  a  small  pavilion,  established  in  1902,  in  the 
Charite,  Berlin,  with  perhaps  a  dozen  beds ;  in  addition  there 
have  been  established  in  Berlin  three  cancer  dispensaries.  Orig- 
inally these  were  combined  with  the  tuberculosis  dispensary, 
but  they  are  now  separated.  In  1910  as  many  as  400  persons 
w^ith  tumors  or  ulcers  sought  advice,  and  in  100  cases  the  diag- 
nosis of  cancer  was  made. 

The  Samariter  Haus  in  Heidelberg  owes  its  origin  to  the 
energy,  and  in  part  also  to  the  munificence,  of  the  famous  sur- 
geon, Czerny.  (See  Section  L)  It  provides  about  60  beds  for 
operable  cases.  In  Hamburg  special  provision  for  cancer  pa- 
tients has  recently  been  made  at  the  Eppendorfer  Hospital,  and 
similar  movements  are  on  foot  in  Cologne,  Dresden,  and  other 
German  towns.  In  Vienna  there  has  been  founded,  under  the 
patronage  of  the  Emperor  Francis  Joseph,  a  Society  for  the 
Erection  of  Hospitals  for  Cancer  Patients.  With  this  list  all 
that  Europe  has  done  or  is  doing  to  provide  such  special  accom- 
modation is  exhausted. 


IN   AMERICA 

Of  the  ISTew  York  City  hospitals  (Bellevue  and  Allied  Hos- 
pitals) only  two  receive  inoperable  cancer  patients.  All  pa- 
tients suffering  from  advanced  or  well-recognized  cancer  are 
referred  to  the  City  Hospital,  Blackwell's  Island,  to  the  ISTew 
York  Skin  and  Cancer  Hospital,  or  to  the  General  Memorial 
Hospital,  and,  in  some  instances  of  patently  incurable  cancer, 
to  the  Almshouse  Hospital  or  to  one  of  the  smaller  benevolent 
institutions  which  receive  such  patients. 


432  THE   CANCER   PROBLEM 

Almshouse  Hospital,  Blackwell's  Island  (New  York  City 
Home  for  Aged  and  Infirm,  Department  of  Pnblic  Charities), 
receives,  and  takes  care  of  nntil  death,  incurable  cancer  pa- 
tients, making  provision  for  any  nnmber  that  may  be  sent  in 
from  the  other  city  hospitals.  Only  indigent  persons,  nat- 
urally, seek  refuge  in  this  institution.  Routine  treatment 
conducive  to  cleanliness  and  comfort  is  given. 

City  Hospital,  Blackwell's  Island  (Department  of  Public 
Charities),  receives  cancer  patients  who  are  amenable  to  sur- 
gical treatment,  those  who  are  considered  inoperable  being  sent 
to  the  Almshouse  Hospital.  None  are  refused  admission.  They 
are  placed  in  the  surgical  ward,  there  being  no  special  can- 
cer ward.  After  operation  the  patients  are  cared  for  until 
death. 

General  Memorial  Hospital  has  two  cancer  wards  in  which 
patients  are  received  who  are  amenable  to  surgical  or  some 
other  form  of  treatment  directed  toward  the  cure  of  the  dis- 
ease. Twenty  beds  (10  for  males  and  10  for  females)  are  re- 
served for  incurable  cases. 

New  York  Skin  and  Cancer  Hospital  has  a  total  capacity  of 
110  beds.  In  the  department  for  the  care  of  advanced  cases 
there  are  beds  for  25.  There  is  a  need  of  accommodation  for 
at  least  100  such  patients.  Plans  are  under  consideration  for 
enlarging  the  hospital  to  250  beds. 


PRIVATE  INSTITUTIONS 

A  limited  number  of  private  institutions  have  departments 
for  the  care  of  individual  cancer  patients,  but  such  institutions, 
of  course,  are  available  only  for  persons  of  means.  Their  ex- 
istence in  no  way  modifies  the  conditions  that  exist  among  the 
poor. 

BENEVOLENT   INSTITUTIONS 

It  is  pertinent  to  note  that  some  of  the  "homes"  and 
other  institutions  of  a  benevolent  or  semi-benevolent  nature 
wtose  object  is  the  care  of  incurable  patients,  do  not  receive 
cancer  patients  because  of  the  belief  that  the  disease  is  con- 
tagious. 

Fordham  Home  for  Incurables,  New  York  City,  receives  in- 
curable cancer  patients,  but  not  free.  A  charge  of  $8.00  per 
week  in  the  wards,  and  $10.00  per  week  in  private  rooms,  is 


INSTITUTIONS    FOR    CANCER    PATIENTS        433 

made.  It  has  accommodation  for  only  six  cancer  patients,  and 
there  is  always  a  waiting  list. 

House  of  Calvary,  New  York  City,  is  maintained  i'or  yjomen 
suffering  from  incurable  cancer.  It  was  established  in  1899, 
under  the  auspices  of  the  Women  of  Calvary,  an  organization 
of  Catholic  widows  who  devote  their  lives  to  the  care  of  in- 
curable cancer  patients.  The  first  House  of  Calvary  was  es- 
tablished in  Lyons,  France,  in  1847.  The  one  in  New  York  is 
the  only  one  in  the  English-speaking  world.  It  is  supported 
by  voluntary  contributions,  is  absolutely  free  to  the  inmates, 
and  is  out  of  debt.  It  is  non-sectarian,  receiving  members  of 
any  creed  and  any  race.  Patients  are  buried  by  the  Society 
when  necessary.  It  has  a  capacity  of  30,  is  always  filled,  and 
generally  has  a  waiting  list. 

St.  Rose's  Free  Home  for  Incurable  Cancer,  New  York  City, 
was  for  a  number  of  years  the  only  place  in  the  city,  barring 
the  Almshouse  Hospital,  in  which  indigent,  incurable  cancer 
patients  could  find  refuge.  It  is  under  the  direction  of  the 
Dominican  Sisters,  the  Servants  of  Relief.  A  new  and  much 
larger  hospital  has  recently  been  erected  by  this  Order.  This 
institution  is  the  city  branch  of  Rosary  Hill  Home,  at  Haw- 
thorne, New  York,  which  is  under  the  direction  of  "Mother 
Alphonse"  (Mrs.  Rose  Hawthorne  Lathrop).  Both  institu- 
tions are  free  and  are  supported  by  voluntary  contributions. 
Patients  are  admitted  without  regard  to  race  or  creed.  If 
necessary  they  are  given  a  decent  burial. 

The  institutions  of  New  York  City  and  immediate  vicinity 
have  been  given  as  a  fair  guide  to  the  possibilities  for  incurable 
cancer  patients  throughout  the  remainder  of  the  United  States. 
There  are  numerous  private  and  semi-private  sanitaria,  hos- 
pitals, and  '^homes''  for  these  unfortunates  in  different  cities, 
but  the  fact  remains  that  provisions  are  nowhere  adequate  for 
the  care  of  patients  afflicted  with  this  disease. 

The  American  Oncologic  Hospital,  Philadelphia,  with  a 
capacity  of  20  beds,  the  Barnard  Free  Skin  and  Cancer  Hos- 
pital, St.  Louis,  with  75  beds,  the  Collis  P.  Huntington  Me- 
morial Hospital,  Boston,  with  26  beds  (see  Section  I),  and  the 
Research  Hospital,  Buffalo,  with  10  beds  (see  Section  I),  are 
illustrations  of  the  limited  special  provision  for  the  care  of 
cancer  patients. 

"aUACK"    CANCER   INSTITUTIONS 

While  legitimate  hospitals  and  benevolent  institutions  are 
refusing  admission  to  this  most  unfortunate  class  of  patients, 


434  THE   CANCER    PROBLEM 

it  is  little  wonder  that  they  turn,  in  their  distress,  to  "quacks," 
who  are  ever  ready  to  receive  those  who  are  able  to  pay  even  a 
moderate  amount. 

The  laws  of  the  various  states  are  such  as  to  foster  institu- 
tionary quackery  of  all  kinds,  and  the  cancer  "specialist"  has 
availed  himself  of  this  leniency  in  the  fullest  measure.  As  a 
consequence,  in  numy  parts  of  the  country  are  to  be  found  in- 
stitutions for  the  treatment  of  cancer  by  means  of  pastes, 
injections,  and  other  non-surgical  methods.  Such  treatment 
helps  to  fill  the  legitimate  homes  for  incurable  cancer  patients, 
but  at  the  same  time  these  "specialists"  are  not  averse  to  pro- 
viding homes  for  such  unfortunates  as  can  continue  to  pay  the 
price  until  the  end. 

Fortunately,  the  campaign  of  education  which  has  been 
waged  against  cancer  has  included  a  crusade  against  these 
blatant  quack  institutions,  and  it  is  to  be  hoped  that  the  time 
is  not  far  distant  when  they  will  form  a  part  of  the  past  history 
of  the  cancer  problem. 


THE   LOT    OF   THE    PATIENT    AT   HOME 

The  life  of  the  victim  of  incurable  cancer  is  a  miserable  one 
under  the  most  advantageous  circumstances;  unless  rendered 
more  bearable  by  proper  care  and  attention  it  must  indeed 
represent  the  maximum  of  misery. 

Imagine  the  discomfort  to  the  patient,  as  well  as  to  other 
members  of  the  household,  when  forced  to  live  out  the  re- 
mainder of  life  within  the  narrow  confines  of  a  tenement-house 
home !  Imagine  the  cross  which  the  care  of  such  a  patient,  no 
matter  how  dearly  beloved,  inflicts  upon  the  busy  mother  of  the 
family,  when  her  heart  is  already  heavy  with  its  weight  of 
poverty  and  hardship,  and  her  hands  are  overburdened  with  a 
multiplicity  of  household  duties ! 

In  pronounced  cases,  with  visible  ulcerations,  and  odors  that 
cannot  be  disguised,  the  patient  must  be  fed  apart  from  the  rest 
of  the  family;  his  clothing  must  be  laundered  separately;  the 
ulcerating  surfaces  must  be  dressed  and  the  dressings  disposed 
of;  while  the  suffering  of  the  afflicted  one  must  be  witnessed 
alike  by  the  old  and  the  young  of  the  household. 

The  unwholesome  mental  and  physical  atmosphere  in  which 
such  a  family  must  live  inaugurates  a  vicious  circle  of  mental 
depression  and  physical  failure  which  toiiches,  to  a  greater  or 
less  degree,  each  member,  and  which  fills  the  patient's  days 
with  the  shadows  of  a  hopeless  night. 


INSTITUTIONS    FOR    CANCER    PATIENTS        435 

No  family  of  limited  means  should  be  forced  to  give,  in  the 
home,  this  care  and  attention  to  a  loved  one  afflicted  with  in- 
curable cancer.  No  person  afflicted  with  incurable  cancer 
should  be  left  to  spend  his  last  days  in  enforced  neglect,  or  in 
the  comparative  comfort  which  he  knows  means  the  discomfort 
of  his  family.  Ample  provision  should  be  made  for  the  proper 
institutional  care  of  all  such  unfortunates. 

Inasmuch  as  the  provision  now  made  for  the  care  of  such 
patients  is  inadequate,  many  persons  of  fair  or  competent 
means,  who  might  avail  themselves  of  the  luxury  of  the  services 
of  trained  or  practical  nurses  who  engage  in  what  is  known  as 
''hourly  nursing,"  meet  with  an  unexpected  difficulty,  in  many 
instances,  in  the  refusal  of  nurses  to  care  for  cancer  patients. 
Many  are  deterred  because  of  the  disagreeable  features  of  the 
work,  and  others  by  a  mistaken  belief  in  the  contagiousness  or 
infectiousness  of  the  disease. 

It  has  been  the  aim  throughout  this  volume  to  avoid  anything 
that  might  disgust,  but  this  subject  cannot  be  dismissed  with- 
out pointing  out  that  the  special  care  required  after  certain 
operations,  for  example,  where  an  artificial  opening  has  been 
made  in  the  intestinal  canal,  ought  to  be  provided  in  institu- 
tions. Even  the  educated  and  wealthy  suffer  if  they  attempt 
to  keep  themselves  clean  instead  of  trusting  to  trained  nurses. 
It  almost  amounts  to  criminal  neglect  to  leave  such  sufferers 
in  the  homes  of  the  poor. 


NEED   FOR  ADEQUATE   FACILITIES 

Since  incurable  cases  of  cancer  are  not  admitted  to  ordinary 
hospitals;  since  they  are  often  ostracized  through  ignorant 
prejudice,  fall  into  the  hands  of  quacks,  or  require  attention 
after  certain  operative  procedures,  it  is  evident  that  a  very 
strong  case  can  be  made  out,  on  humanitarian  grounds  alone, 
for  better  facilities  for  their  care.  In  view  of  the  foregoing 
facts,  when  one  has  studied  the  statistics  of  cancer,  as  given  in 
Section  III,  it  becomes  evident  that  a  large  number  of  persons 
must  die  each  year  without  the  care  and  treatment  which  should 
be  accorded  to  them.  If  this  applies  to  New  York  City  and 
vicinity,  it  is  reasonable  to  suppose  that  it  applies  in  greater 
measure  to  other  parts  of  the  country  and,  indeed,  reference 
to  other  countries  shows  that  throughout  the  civilized  world 
the  same  neglect  obtains. 

It  is  also  apparent  that  none  of  the  facilities  which  the  De- 
partment of  Public  Charities  of  New  York  City  supplies  are 


436  THE   CANCER    PROBLEM 

adequate  to  meet  the  need,  inasmuch  as  there  are  many  cancer 
patients  who,  ahhoiigh  poor,  do  not  come  under  the  categorv  of 
"the  indigent."  It  is  further  apparent  that  the  few  places  to 
which  the  indigent  poor  can  go  and  spend  their  remaining 
days  in  comparative  peace  and  quiet  (other  than  the  Almshouse 
Hospital)  accommodate  so  few  that  it  is  as  nothing  compared 
with  the  number  affected.  The  victim  of  incurable  cancer 
should  not  be  forced  to  decide  between  remaining  a  burden  to 
family  audi  friends,  or  going  to  a  hospital  or  "home"  for  indi- 
gents. There  should  be  ample  provision  in  every  commimity 
from  which  this  most  unfortunate  class  of  patients  may  make 
selection. 

As  there  is  need  of  better  facilities  for  the  care  of  patients 
in  all  stages  of  cancer,  particularly  during  the  deplorable  period 
when  the  disease  is  irremovable,  perhaps  inoperable,  and  cer- 
tainly incurable,  so  is  there  a  need  for  better  facilities  for  the 
care  of  these  unfortunates  as  they  approach  the  end.  It  is 
frightful  to  contemplate  the  state  of  affairs  often  found  in  the 
wards  of  institutions  for  the  care  of  cancer  patients,  where  the 
dying  are  left  in  the  midst  of  the  living  for  hours  and  some- 
times, in  lingering  cases,  even  for  days.  The  psychic  effect 
upon  other  patients  is  distressing  in  the  extreme,  and  some- 
times days  pass  before  the  ward  is  restored  to  its  normal 
composure.  This  is  not  as  it  should  be.  As  soon  as  the  signs 
of  dissolution  become  manifest  the  patient  should  be  removed 
to  a  room  set  apart  for  the  purpose.  Here  friends,  relatives, 
and  religious  counselors  may  remain  to  the  end  without  having 
their  sacred  privacy  invaded  by  the  presence  of  other  patients 
and  attendants.  Other  occupants  of  the  ward  are  thus  spared 
the  harrowing  scenes  which  so  often  attend  the  death  of  cancer 
victims, 

SUMMARY 

The  investigation  of  the  facilities  for  the  care  of  cancer 
patients  has  served  to  emphasize,  more  than  anything  else  has 
done,  the  need  of  some  sort  of  a  campaign  of  education,  some 
more  decisive  and  concerted  cooperation  with  the  various  chari- 
table institutions  and  hospitals  in  searching  out  and  reaching 
the  poor  who  are  afflicted  with  cancer,  in  whatever  stage.  An 
enormous  amount  of  good  could  be  accomplished  if  special 
cancer  hospitals,  or,  failing  these,  the  general  hospitals,  would 
send  out  intelligent  and  tactful  representatives  to  visit  the 
various  benevolent  homes,  departments  of  public  charities,  so- 
cieties  for   improving  the  condition   of  the   poor,   and   other 


IxXSTITUTIONS    FOR    CANCER     PATIENTS         437 

similar  organizations,  for  the  purpose  of  getting  in  touch  with 
cancer  patients  and  their  families  where  there  is  no  medical 
attendance.  Such  cooperation  would  be  invaluable  from  a 
statistical  point  of  view  as  well  as  from  that  of  the  humani- 
tarian. 

Moreover,  such  an  investigation  would  serve  the  further  pur- 
pose of  emphasizing  the  importance  of  early  and  accurate  diag- 
nosis, with  reference,  not  only  to  the  presence  of  malignancy, 
but  to  the  stage  of  development  of  the  disease.  It  is  always  to  be 
borne  in  mind  that  many  cases  of  cancer  are  pronounced  in- 
operable and  hence  incurable  when  they  may  be  both  operable 
and  curable.  One  should  be  loath,  therefore,  to  consign  a 
patient  to  the  category  of  the  inoperable  and  incurable  until 
every  expedient  known  to  modern  medical  science  as  applied 
to  the  diagnosis  and  treatment  of  malignant  disease  has  been 
employed. 


SECTION    XIV 

THE  CAMPAIGN  OF  EDUCATION  CONCERNING 

CANCER 

INTRODUCTORY    REMARKS 

Campaigns  of  education  have  played  a  conspicuous  part  in 
the  development  of  practically  every  great  movement  which  has 
had  for  its  purpose  the  betterment  of  living  conditions,  the 
eradication  of  sources  of  contamination  leading  to  disease,  and 
the  maintenance  of  the  health  of  the  individual  and  of  the 
population  as  a  whole.  In  some  countries,  and  in  certain  in- 
stances in  all  countries,  the  dissemination  of  knowledge  along 
these  lines  has  been  so  gradual  and  so  unobtrusive  that  it  may 
hardly  be  called  a  campaign.  The  history  of  medicine  is 
marked  by  instances  of  this  character,  the  most  notable  of 
which,  perhaps,  relate  to  vaccination  for  smallpox,  to  the  con- 
trol of  yellow  fever,  and  to  the  crusades  against  malarial  and 
typhoid  fever. 

In  other  instances  definite  campaigns  of  education  have  been 
inaugurated  and  vigorously  carried  on,  the  most  notable  being 
those  directed  against  tuberculosis,  to  a  lesser  extent  against 
venereal  diseases,  and,  lately,  against  cancer. 

While  the  apparent  increase  in  the  number  of  those  afilicted 
with  malignant  disease  is  creating  a  public  interest  which  is 
being  fanned  into  hysteria  by  sensational  newspaper  accounts 
of  notable  cases  and  possible  "cures,"  there  come  urgent  calls, 
from  laymen  as  well  as  from  members  of  the  medical  profes- 
sion, for  a  more  definite  crusade,  a  more  vigorous  campaign  of 
education,  against  cancer. 

When  it  is  noted — to  quote  only  two  of  the  many  recent 
utterances  on  the  subject — that  an  important  body  of  public- 
spirited  citizens,  in  an  earnest  desire  to  be  helpful,  advocates 
the  publication  of  a  "cancer  primer"  for  use  in  the  schools; 
and  that  a  prominent  surgeon,  before  a  general  lay  audience, 
calls  for  the  removal  by  the  knife,  within  twenty-four  hours 

438 


CAMPAIGN    OF    EDUCATION  439 

after  its  discovery,  of  every  lump  in  a  woman's  breast — it  be- 
comes evident  that  the  campaign  of  education  concerning  cancer 
must  be  continued  with  discretion.  It  must  be  conducted  on  a 
basis  entirely  different  from  that  on  which  the  fight  against 
tuberculosis  is  waged. 

In  the  case  of  tuberculosis,  the  essential  cause — the  tu- 
bercle bacillus — and  the  predisposing  causes — inherited  ten- 
dency, lowered  vitality,  and  unsanitary  surroundings — are 
established;  the  infectiousness  of  the  disease  is  generally  con- 
ceded, and  the  cure,  when  a  cure  is  possible,  is  understood. 

The  situation  with  regard  to  cancer  is  entirely  different. 
The  essential  cause  is  not  yet  discovered,  the  predisposing 
causes  are  matters  subject  to  widely  different  opinions,  and  the 
cure,  by  other  means  than  by  surgical  removal  of  the  local  mani- 
festations of  the  disease,  is  by  no  means  determined. 

It  scarcely  need  be  pointed  out,  therefore,  that  if  such  a 
campaign  is  not  cautiously  guarded  and  wisely  conducted,  with 
a  grasp  of  all  sides  of  the  cancer  problem,  there  is  danger  of 
far-reaching  harm.  The  public,  tossed  from  pillar  to  post,  so 
to  speak,  by  differing  medical  opinions,  will  be  inclined  to  dis- 
credit the  profession  and  to  ignore  its  warnings.  There  will 
then  arise  a  tendency  to  settle  back  into  hopeless  inertia,  or  to 
fall  into  a  state  of  morbid  introspection  or  hysterical  watching 
for  danger  signals,  with  resulting  physical  and  mental  unrest 
which  may  prove  a  predisposing  factor  in  the  initiation  of  the 
very  disease  the  dissemination  of  knowledge  is  intended  to 
eradicate. 

Before  a  campaign  of  education  concerning  cancer  can  be 
effectively  inaugurated  and  successfully  conducted  it  is  neces- 
sary to  determine  what  is  actually  known  to-day  about  the  dis- 
ease; what  may,  with  expediency,  be  imparted  to  the  general 
public ;  and  through  what  channels  such  information  may  best 
be  conveyed. 

It  will  thus  be  seen  that  the  plan  of  a  campaign  is  of  necessity 
complex,  involving,  first,  the  education  of  the  medical  profes- 
sion, and,  second,  the  education  of  the  public — not  the  reverse. 

In  England,  at  the  time  of  going  to  press,  the  question  of 
such  education  is  still  being  debated.  The  health  committees  of 
some  municipalities  appear  inclined  to  inaugurate  a  plan  of  edu- 
cating the  public  by  means  of  lectures  to  nurses,  midwives,  and 
all  who  are  interested  in  social  and  hygienic  work.  It  is  still 
doubtful  whether  any  organized  campaign  will  be  undertaken 
along  these  lines.  The  sporadic  efforts  in  this  direction  have 
not  been  in  progress  long  enough  to  permit  of  an  opinion  as  to 
their  possible  utility. 


440  THE   CANCER    PROBLEM 

In  1913  the  London  Cancer  Hospital  arranged  courses  of 
post-graduate  lectures  similar  to  those  of  the  New  York  Skin 
and  Cancer  Hospital.  The  vigorous  and  lucid  campaign  con- 
ducted in  England  hy  the  late  Sir  Henry  Butlin  concerning  the 
early  diagnosis  of  cancer  has  not  yet  found  an  imitator.  With- 
out official  sanction,  and,  indeed,  without  official  enforcement 
throughout  the  country,  it  does  not  seem  that  an  organized 
plan  of  education  of  the  public  is  likely  to  succeed,  since  efforts 
to  obtain  compulsory  notification  have  not  been  supported  by 
the  govermnent. 

The  situation  in  England  resembles  that  in  France,  where 
division  of  opinion  on  the  part  of  the  authorities  has  as  yet  pre- 
vented any  action  being  taken. 


THE   EDTICATION   OF   THE   MEDICAL   PROFESSION 

Modern  medicine  is  so  far-reaching  and  comprehensive  in 
its  scope  that  it  is  manifestly  impossible  for  each  man  and 
woman  upon  whom  the  degree  of  doctor  of  medicine  is  conferred 
to  be  expert  in  the  diagnosis  of  cancer,  either  by  microscopical 
study  or  clinical  examination.  Yet,  in  a  large  proportion  of 
cases,  it  is  the  general  practitioner,  the  dermatologist,  the 
gynecologist,  or  the  specialist  in  any  field,  who  is  first  consulted, 
and  who  has,  therefore,  the  first  opportunity  to  diagnose  malig- 
nant disease,  while  the  surgeon  is  the  court  of  last  appeal,  being 
resorted  to  only  too  often,  when  the  case  is  hopeless. 

This  being  the  case,  the  surgeon,  who  sees  so  much  of  the 
ultimate  outcome  of  cancer,  feels  most  keenly  the  paramount 
importance  of  early  and  correct  diagnosis  and  of  the  prompt 
institution  of  the  proper  treatment.  It  is  inevitable,  too,  that 
the  surgeon  should  attribute  much  of  the  responsibility  for  the 
lack  of  correct  diagnosis  and  proper  treatment  to  those  who  are 
first  consulted. 

It  is  evident,  then,  that  the  campaign  of  education  must  be 
initiated  within  the  medical  profession.  The  general  physician, 
the  specialist  in  every  branch  of  medicine,  and  the  dentist  as 
well,  must  be  trained  to  recognize  and  to  guard  against  pre- 
cancerous and  early  cancerous  conditions.  Just  so  long  as  the 
family  physician  says  to  a  female  patient,  particularly  one  who 
is  passing  through  the  so-called  "cancer  age,"  who  has  a  small 
lump  in  the  breast,  subject,  perhaps,  to  irritation  by  the  corset: 
"Leave  it  alone !  It  is  nothing  unless  it  pains  you ;  stop  think- 
ing about  it!"  or,  to  a  male  patient  who  has  an  elevated  birth- 
mark, so  situated  that  it  is  rubbed,  perhaps,  by  a  hat-band  or 


CAMPAIGN    OF    EDUCATION  441 

suspender  buckle:  "This  is  nothing  but  a  birth-mark,  how 
could  it  hurt  you  ?  Come  to  see  me  when  you  have  something 
the  matter  with  you" — just  so  long  is  there  real  and  vital  need 
of  a  campaign  of  education  against  cancer  among  physicians. 
There  is  need  that  they  should  be  taught  either  to  treat  such 
conditions  in  accordance  with  the  accepted  facts  concerning 
the  disease,  or  to  refer  such  patients  at  once  to  surgeons  or 
specialists  of  wider  experience. 

In  this  connection  it  is  wise  to  impress  upon  the  rank  and 
file  of  the  profession  certain  broad  facts  which  are  seemingly 
fundamental : 

(1)  That  with  the  increase  in  the  number  of  cases  of  cancer 
reported  all  over  the  world,  and  with  the  wider  interest  con- 
cerning the  disease,  all  physicians  must  meet  an  increased  re- 
sponsibility. 

(2)  That  this  increased  responsibility,  of  necessity,  demands 
increased  knowledge. 

(3)  That  increased  responsibility  and  increased  knowledge 
call  for  the  highest  ethical  standard  on  the  part  of  the  medical 
profession  in  its  management  of  cases  in  which  the  cancer 
problem  is  involved,  making  it  incumbent  upon  the  physician 
or  surgeon  to  treat  each  case  according  to  the  best  interest  of 
the  patient — to  operate  when  necessary,  and  to  refrain  from 
operating  when  that  course  seems  desirable. 

(4)  That  this  increased  responsibility  calls  for  a  union  of 
the  medical  profession  upon  the  essential  questions  concerning 
cancer;  the  adjustment  of  differences  of  opinion  among  them- 
selves; and  the  discussion  in  public  of  only  those  phases  of  the 
subject  which  may  tend  to  promote  early  diagnosis  and  prompt 
surgical  treatment. 

If  every  practitioner  of  medicine,  in  any  of  its  branches, 
were  familiar  with  the  predisposing  factors  in  the  production 
of  cancer,  able  to  note  all  the  conditions  which  come  under  the 
head  of  precancerous,  and  qualified  to  give  wise  advice  and 
proper  instruction,  in  accord  with  the  most  recent  discoveries, 
rapid  strides  would  be  made  toward  the  eradication  of  at  least 
some  of  the  common  forms  of  the  disease. 

In  Section  IV,  Chapter  2,  the  predisposing  causes  of  cancer 
are  discussed,  and  in  Section  VIII  the  subject  of  prevention 
by  proper  attention  to  these  is  considered.  The  etiologic  sig- 
nificance of  the  various  predisposing  factors  is  now  sufficiently 
well  established  for  it  to  be  obligatory  upon  all  who  assume  the 
responsibility  of  caring  for  cancer  patients  to  be  familiar  with 
them,  and  to  inaugurate  treatment  in  accordance  with  such 
knowledge. 


442  THE   CANCER    PROBLEM 

With  the  establishment  of  cancer  hospitals,  and  cancer  de- 
partments in  connection  with  general  hospitals,  and  with  the 
fact  that  more  patients  are  being  operated  upon  during  the 
earlier  stages  of  the  disease  than  was  formerly  the  case,  it  is 
emphatically  the  duty  of  the  men  connected  with  these  insti- 
tutions, through  lectures,  clinical  demonstrations,  etc.,  to  dis- 
seminate knowledge  among  those  who  form  the  body  of  the 
profession.  Thus  the  standard  of  diagnosis  may  be  raised  so 
that  the  family  physician,  the  specialist  in  other  lines,  and  the 
dentist  will  be  on  guard  against  the  small  beginnings.  They 
will  then  cooperate  with  the  surgeon,  and  together  they  will  be 
able  to  forestall  many  of  the  disastrous  endings  to  which  neglect 
or  mistakes  in  diagnosis  so  often  lead. 

With  this  end  in  view,  for  a  number  of  years,  the  New  York 
Skin  and  Cancer  Hospital  has  conducted  two  operative  clinics 
each  week,  and  one  or  more  annual  lectures  have  been  given, 
with  the  presentation  of  patients,  specimens,  and  other  illus- 
trations of  the  difFerent  phases  of  actual  work.  Reports  of  this 
educational  work  have  been  made  from  time  to  time,  and  thus 
thousands  of  physicians,  from  all  parts  of  the  country,  have 
been  helped  by  an  extensive  practical  experience,  which  in  this 
hospital  embraces  every  phase  of  malignant  disease,  from  the 
benign,  precancerous  wart  or  mole,  to  the  most  extensive,  irre- 
movable, and  inoperable  manifestation  of  cancer.  Not  only  by 
means  of  patients  who  represent  the  different  stages  of  the 
disease,  but  with  stereopticon  pictures,  wax  casts,  and  various 
other  illustrative  material,  both  the  negative  and  positive  sides 
of  the  subject,  from  the  point  of  view  of  diagnosis,  have  been 
emphasized. 

While  the  careless  and  possibly  uninformed  attitude  of  the 
physician  is  not  as  common  now  as  formerly,  it  is  still  found 
all  too  frequently,  and  has  helped  materially  to  swell  the  en- 
rollment of  patients  in  cancer  hospitals  and  homes  for  the  in- 
curable. On  the  other  hand,  since  the  inauguration  of  the 
campaign  of  education  on  the  subject,  there  is  a  growing  need 
of  care  lest  the  pendulum  swing  too  far  in  the  other  direction — 
lest  "radical  removal"  may  be  the  advice  as  freely  and  thought- 
lessly given  as  was  formerly  the  case  with  "Let  it  alone !" 

This  tendency  to  rush  to  extremes  is  a  telling  argument  in 
support  of  conducting  the  campaign  of  education  against  can- 
cer first  among  the  medical  profession.  The  importance  of 
studying  cases  should  be  emphasized,  and  the  discussion  of 
theoretical  questions  left  to  investigators  who  are  learned  in  the 
technicalities  of  biology  and  pathology. 

A  few  cases  that  have  recently  come  under  my  notice  are 


CAMPAIGN    OF    EDUCATION  443 

illustrative  of  these  points.  In  brief  outline  their  histories  are 
given  below. 

Case  I. — ^A  young  married  woman,  33  years  old,  with  two 
children,  the  youngest  six  and  a  half  years  of  age,  recently 
noticed  a  little  milk  in  the  left  breast.  Having  previously 
undergone  an  operation  for  the  removal  of  a  small  adenosar- 
coma  from  the  right  breast,  she  became  alarmed  about  the  con- 
dition in  the  other.  The  family  physician  was  consulted.  He 
assured  her  that  the  breast  should  be  removed  at  once.  The 
condition  was  due  to  slight  inflammation,  with  temporary 
glandular  activity,  at  the  time  of  menstruation,  and  promptly 
subsided  without  treatment.  Had  she  taken  the  physician's 
advice,  based  upon  an  error  in  diagnosis,  unnecessary  mutila- 
tion would  have  resulted. 

Case  II. — A  married  woman,  forty  years  old,  with  no  chil- 
dren, was  advised  by  the  family  physician  to  have  the  entire 
breast  and  the  axillary  glands  removed  for  a  small  tumor  which 
was  obviously  a  lipoma.  The  patient  was  told  she  had  advanced 
cancer.  The  small  fatty  tumor  was  removed  and  the  diagnosis, 
substantiated  by  microscopic  examination,  proved  the  fallacy 
of  the  advice  first  given. 

Case  III. — A  physician's  sister,  35  years  of  age,  unmarried, 
with  some  of  the  classical  symptoms  of  chronic  intestinal  stasis, 
had  a  lumpy  condition  in  the  breast.  She  had  been  reading 
about  cancer,  and,  upon  the  advice  of  two  physicians,  decided 
to  have  the  breast  removed.  I  advised  against  operation,  urg- 
ing general  treatment,  but  the  patient  went  elsewhere  and  was 
operated  upon.  The  microscope  showed  no  malignancy.  The 
condition,  which  was  doubtless  due  to  the  chronic  intestinal 
stasis,  would  in  all  probability  have  disappeared  under  treat- 
ment for  the  stasis.  Had  she  taken  such  treatment  she  prob- 
ably would  have  been  less  of  a  nervous  invalid  than  she  is  to- 
day, and  certainly  would  not  be  the  mutilated  individual  she 
now  is. 

Case  IV. — A  single  woman,  32  years  of  age,  who  had  been 
suffering  from  sciatica,  noticed  a  very  small  lump  in  the  left 
breast.  She  was  advised  by  the  family  physician  to  have  the 
breast  removed  without  any  delay,  for  what  he  pronounced 
undoubted  advanced  cancer.  Upon  examination  I  found  bi- 
lateral retraction  of  the  nipple,  which  was  congenital,  accord- 
ing to  the  history.  This  was  not  discovered  by  the  physician, 
who  did  not  make  a  bilateral  examination.  Under  anti-rheu- 
matic treatment  the  condition  cleared  up  promptly,  except  for 
the  retraction  of  the  nipple. 

Case  V. — A  woman,  63  years  of  age.     Left  breast  had  been 


444  THE   CANCER    PROBLEM 

removed  for  cancer  fifteen  years  earlier.  I  removed  the  right 
breast  for  very  early  cancer  five  years  ago.  Three  years  ago 
she  returned,  complaining  of  tender  spots  over  the  ribs  on  the 
right  side.  Upon  examination  small  nodules  were  found, 
closely  adherent  to  the  ribs  of  the  right  side,  and  a  few  on  the 
left  side,  which  had  been  pronounced  advanced  recurrent  can- 
cer. A  few  days  of  anti-rheumatic  treatment  cleared  up  the 
spots  of  tenderness  and  the  nodules.  The  patient  has  had  no 
further  trouble,  but  must  be  careful  with  reference  to  gout  and 
rheumatism. 

Case  VI. — A  single  woman,  of  middle  age,  consulted  me  on 
account  of  a  tumor,  of  considerable  size,  in  the  left  breast. 
There  was  some  retraction  of  the  nipple.  The  condition  had 
been  diagnosed  as  advanced  cancer,  and  she  had  been  advised 
to  have  the  breast  removed.  Suspecting  syphilis  a  blood  test 
was  made  and  proved  positive.  The  tumor  disappeared  com- 
pletely under  proper  medical  treatment. 

Case  VII. — A  single  woman,  34  years  of  age,  was  told  that 
she  had  advanced  cancer  of  the  right  breast,  which  was  beyond 
operation.  Upon  examination  the  following  conditions  were 
found :  A  tumor  about  the  size  of  a  small  orange  in  the  right 
breast ;  an  inflammatory  area  around  the  nipple ;  a  small  dis- 
charging sinus  within  this  area  of  inflammation ;  some  swelling 
of  the  axillary  glands.  It  was  a  typical  case  of  tuberculous 
sinus  of  the  breast.  A  few  days  with  local  antiseptic  treatment 
applied  to  the  breast  caused  the  disappearance  of  the  swelling 
in  the  axilla.  The  breast  was  removed,  and  pathological  ex- 
amination showed  no  evidence  of  cancer.  The  patient  has 
remained  well  for  some  years,  with  freedom  from  the  thought 
of  cancer. 

Case  VIII. — A  woman,  28  years  of  age,  married,  with  one 
child,  consulted  me  recently  for  subdeltoid  bursitis.  The  typ- 
ical history  of  chronic  intestinal  stasis  of  long  duration  was 
elicited — marked  and  obstinate  constipation,  abdominal  pain, 
headache,  loss  of  appetite,  loss  of  weight,  acrid  perspiration, 
cold  and  clammy  hands,  etc.  A  nodular,  more  or  less  painful, 
condition  in  both  breasts  was  found  in  the  upper  and  outer 
quadrant,  which  had  been  pronounced  cancer  by  several  physi- 
cians. Suspecting  that  the  condition  in  the  breasts  was  a  mani- 
festation of  stasis,  I  put  the  patient  upon  large  doses  of  Kussian 
mineral  oil,  and  a  dietary  and  hygienic  regime,  with  the  result 
that  the  symptoms,  including  the  painful  and  lumpy  condition, 
were  markedly  improved.  I  have  seen  a  number  of  similar  cases 
in  my  own  practice  and  in  the  wards  of  Guy's  Hospital,  Lon- 
don, service  of  Sir  W.  Arbuthnot  Lane. 


CAMPAIGN    OF    EDUCATION  445 

In  numbers  of  instances  menstrual  lumps  in  the  breast  have 
been  mistaken  for  cancer. 

Such  cases  emphasize  one  side  of  the  question  of  mistaken 
diagnosis.  Every  case  of  advanced  cancer  of  the  breast  may 
be  said  to  emphasize  the  other  side,  which  leads  to  neglect  or 
delay.  All  cases,  vv^hether  the  mistake  in  diagnosis  be  positive 
or  negative  as  regards  cancer,  emphasize  the  importance  of  a 
unification  of  knovi^ledge  concerning  the  known  facts  in  rela- 
tion to  malignant  disease. 

It  should  be  impressed  upon  the  body  of  the  medical  profes- 
sion that,  as  a  rule,  they  should  entrust  the  experimental  inves- 
tigation of  cancer  to  reliable  research  institutions,  where  all 
theories,  whether  of  cause  or  cure,  are  studied  on  a  scientific 
basis,  without  danger  to  the  victims  of  the  disease.  In  excep- 
tional instances,  men  and  women  with  excellent  medical  train- 
ing, but  with  no  institutional  affiliations,  may  work  indepen- 
dently, and  their  efforts  should  be  encouraged.  On  the  other 
hand,  unscrupulous  or  overconfident  physicians,  working  inde- 
pendently, may  do  incalculable  harm,  for  example,  by  testing 
their  theories  of  treatment  upon  trusting  patients  until  it  is 
too  late  for  surgical  intervention,  and  consequently  too  late  for 
cure. 

It  is  no  uncommon  occurrence  for  physicians  to  appeal  to 
the  New  York  Skin  and  Cancer  Hospital,  and  doubtless  other 
similar  institutions  have  a  like  experience,  for  "cancer  ma- 
terial" with  which  to  make  a  "serum"  or  "vaccine"  or  other 
"cure,"  in  accordance  with  some  new  theory  of  treatment. 
Some  of  these  applicants,  who  are  not  prompted  by  high  or 
sincere  motives,  have  been  known  to  boast  of  their  "researches," 
thus  wilfully  playing  upon  the  ignorance  or  credulity  of  their 
patients,  while  at  the  same  time  they  enrich  themselves.  The 
patient,  meanwhile,  may  be  richer  in  experience  but  poorer  in 
money,  and  is  often  bankrupt  as  far  as  his  chances  for  recovery 
are  concerned.  The  eradication  of  this  kind  of  "research" 
should  be  a  part  of  the  work  of  education. 


THE  EDUCATION  OF  THE  PUBLIC 

NEED    THE    LAYMAN    BE    INSTRUCTED? 

The  need  for  the  enlightenment  of  the  laity  concerning  can- 
cer is  twofold:  (1)  For  the  establishment  of  a  spirit  of  con- 
fidence in,  and  of  willingness  to  cooperate  with,  the  medical 
profession  in  the  prevention  of  cancer  by  intelligent  attention 


446  THE   CANCER    PROBLEM 

to  the  general  health  and  to  the  special  conditions  which  pre- 
dispose to  the  development  of  the  disease,  as  outlined  in  Sec- 
tion IV,  Chapter  2  {Predisposing  Causes),  and  Section  VIII 
(Prophylaxis).  (2)  For  the  development  of  keener  discrim- 
ination in  the  selection  of  a  physician  or  surgeon.  The  public 
should  be  sufficiently  instructed  concerning  the  ethical  princi- 
ples which  govern  the  conduct  of  the  recognized  body  of  the 
medical  profession  to  be  able  to  differentiate  between  the 
capable  and  conscientious  practitioner  and  the  "quack"  who, 
solely  by  virtue  of  a  medical  license,  has  power  to  attract  and  to 
delude  the  suffering. 

Unfortunately,  in  no  country  to-day  is  the  medical  law  so 
constituted  and  so  administered  as  to  entirely  eliminate  the 
unscrupulous  practitioner  and  the  "quack."  Even  the  most 
intelligent  members  of  the  non-medical  part  of  a  community 
may  be  deceived  by  such  members  of  the  profession.  Interest- 
ing illustrations  of  this  are  cited  in  Section  IX,  The  Investi- 
gation of  "Cancer  Cures." 

The  imminence  and  extent  of  the  danger  from  quackery  are 
greater  than  is  generally  realized.  The  advertisements  of  men 
who  may  be  rightly  classed  as  cancer  quacks  are  published  in 
glaring  type  in  an  alluring  phraseology  in  many  of  the  leading 
periodicals,  both  secular  and  religious.  So  far,  in  most  states 
and  countries,  medical  laws  have  proved  inadequate  for  the 
suppression  of  this  practice.  Even  for  communications  such  as 
those  referred  to  by  Paget,  in  the  following  letter,  there  seems 
no  adequate  redress.  Unfortunately,  there  is  always  danger 
that  many  such  statements  as  those  to  which  he  directs  atten- 
tion may  go  without  contradiction,  or  that,  when  published,  such 
contradiction  may  not  reach  the  readers  who  may  have  been  in- 
fluenced by  the  assertions  contradicted. 

"CANCER  AND  ANTI-VIVISECTION." 

"To  THE  Editor  of  the  Daily  Mail." 

"Sir: — A  new  anti- vivisection  magazine  has  lately  appeared;  it  is 
called  the  Journal  of  the  Society  for  the  Prevention  and  Relief  of  Cancer. 
It  contains  half  a  page  of  sentences  quoted  from  another  magazine, 
called  the  Health  Record.  These  sentences  are  adverse  to  the  treatment 
of  cancer  by  operation;  and  they  are  put  as  quotations  from  Sir  Benjamin 
Brodie,  Professor  Syme,  Sir  James  Paget,  and  others. 

"Brodie  died  fifty-one  years  ago,  and  Syme  forty-three  years  ago. 
Statements  made  more  than  half  a  century  back,  when  the  conditions 
and  methods  of  surgery  were  very  different  from  what  they  are  now,  ought 
not  to  be  quoted  without  dates  put  to  them.  Neither  are  any  references 
given.  Without  dates  and  references,  we  cannot  be  sure  that  these 
statements  were  ever  made.    But  we  can  be  quite  sure  that  neither 


CAMPAIGN    OF    EDUCATION  447 

Brodie,  Syme  nor  Paget,  were  they  living  now,  would  dream  of  saying 
anything  of  the  kind.  They  would  condemn  with  unsparing  anger  the 
use  which  has  been  made  of  their  names. 

"(Signed)  Stephen  Paget. 
Hon.  Secretary  Research  Defense  Society, 
21,  Ladbroke  Square,  W.,  London." 

It  often  happens  that  literature,  such  as  that  denounced 
above,  emanates  from  persons  holding  medical  degrees,  whose 
writings,  therefore,  are  very  dangerous.  A  medical  man  is 
privileged  to  hold  any  opinion  he  chooses  concerning  the  na- 
ture, cause,  treatment,  or  even  the  cure  of  cancer  or  any  other 
disease,  provided  that  he  holds  his  views  honestly.  But  it  is  a 
different  matter  when  statements  in  the  public  press  are 
clothed  in  the  catch  phraseology  of  avowed  quacks,  and  when 
the  appeal  is  made  to  a  low  order  of  intelligence  and  not  to  edu- 
cated medical  opinion.  Moreover,  unreliability  is  always  evi- 
dent when  cases  given  by  way  of  illustration  of  the  claims  made, 
are  incapable  of  independent  verification.  Much  literature  of 
this  character  has  been  published  which  is  but  veiled  advertise- 
ment of  the  author's  claims  to  be  a  "cancer  expert." 

The  average  layman,  who  looks  upon  the  question  of  medical 
ethics  from  the  business  point  of  view,  sees  nothing  amiss  in 
the  fact  that  Dr.  So-and-So  advertises  to  cure  cancer.  The 
extravagant  claims  of  the  complete  eradication  of  cancer — 
"roots  and  all" — without  the  use  of  the  surgeon's  knife,  appeal 
to  many  victims  of  the  disease.  The  advertising  doctor  is  taken 
on  faith — and  eventually  the  patient  comes,  often  without 
money,  without  hope,  and  with  not  the  slightest  chance  of  cure, 
to  the  cancer  hospital. 

The  public  needs,  therefore,  to  be  taught  the  difference  be- 
tween the  man  who,  independently,  and  without  the  sanction 
of  the  medical  profession,  advertises  to  "cure"  cancer,  and  the 
skilled,  conscientious,  and  recognized  members  of  the  profes- 
sion who  are  carefully  safeguarding  the  patient  while  dili- 
gently striving  to  solve  the  cancer  problem.  Much  excellent 
educational  work  along  this  line  has  already  been  accomplished 
by  secular  journals,  medical  journals,  medical  societies,  and  by 
popular  lectures,  etc.,  but  much  remains  yet  to  be  done. 


HOW  BEST  TO  CONDUCT  THE  CAMPAIGN  OF  EDUCATION? 

The  above  is  still  a  mooted  question.  Among  other  experi- 
ments along  this  line,  for  a  number  of  years,  Winter,  Pinkus, 
and  von  Duehrrsen  have  been  sending  broadcast  throughout 


448  THE   CANCER   PROBLEM 

Germany  circulars  of  information  and  instruction  for  women, 
with  especial  reference  to  cancer  of  the  pelvic  organs.  They 
have  also  caused  similar  matter  to  be  published  in  the  secular 
press  at  stated  intervals.  At  first  it  was  reported  that,  as  a 
consequence  of  this  form  of  enlightenment,  the  number  of 
women  who  presented  themselves  at  the  clinics  of  these  sur- 
geons while  yet  in  the  early  and  curable  stages  of  such  cancers, 
increased  year  by  year.  Later  accounts  do  not  substantiate  the 
first  reports  as  regards  the  number  of  women  directly  present- 
ing themselves,  although  it  appears  that  much  good  has  resulted 
from  the  instructions  issued  to  midwives. 

In  this  connection  it  is  interesting  to  note  the  following 
statement  from  H.  J.  Boldt,^  Professor  of  Gynecology,  of  the 
]^ew  York  Post-Graduate  Medical  School  and  Hospital,  who 
has  recently  made  a  study  of  the  practical  application  of  this 
plan  of  publicity.  ''During  the  past  summer,"  he  says,  "I  had 
an  opportunity  to  converse  with  a  number  of  men  who  are  con- 
nected with  university  hospitals  and  who  have  studied  care- 
fully the  question  of  publicity.  Those  to  whom  I  put  the  ques- 
tion assured  me  that  they  did  not  find  any  advantageous  result. 
They  had  seen  no  larger  percentage  of  operable  cases  since  the 
'Winter'  circular  letters  had  been  sent  out,  and  since  the  lay 
press  had  published  articles  written  by  Winter  on  the  subject 
of  uterine  cancer.  What  they  had  observed,  following  the 
general  publicity  in  the  lay  press,  was  that  'a  goodly  number 
of  neurasthenic  women  were  made  more  nervous  and  consulted 
physicians  in  fear  of  cancer.'  " 

"It  is  my  opinion,"  continues  Boldt,  "strengthened  by  this 
information  obtained  abroad,  that  we  are  not  likely  to  get  under 
observation  a  larger  percentage  of  incipient  cases  of  cancer  of 
the  uterus  by  giving  the  cancer  symptoms  to  the  public  through 
the  medium  of  the  lay  press.  On  the  contrary,  it  is  more  than 
likely  that,  of  the  large  number  of  women  suffering  from 
leukorrhea,  those  of  the  neurasthenic  type  will  simply  acquire 
an  aggravation  of  their  nervousness,  with  this  result:  They 
will  rush  to  physicians  for  examination,  and,  if  told  they  have 
no  malignant  disease,  will  be  distrustful,  and  seek  the  advice 
of  others.  I  am  convinced,  therefore,  that  the  better  way — the 
only  rational  way,  indeed — is  to  impress  on  the  profession  the 
grave  importance  of  being  conscientious  in  the  matter  of  exam- 
ination, and  never  superficial." 

^  Boldt,  H.  J. — ' '  How  May  We  Eeduce  the  Mortality  from  Cancer  of  the 
Uterus?  With  Special  Reference  to  Treatment  and  to  Publicity  Through 
the  Lay  Press,"  Jour.  Am.  Med.  Assn.,  Vol.  LX,  March   29,   1913,  pp. 

968-972. 


CAMPAIGN    OF    EDUCATION  44^ 

Many  physicians  are  of  the  opinion  that  all  teaching  on  the 
subject  of  cancer  should  emanate  from  the  family  physician. 
If  all  homes  were  at  all  times  in  touch  with  a  family  physician 
sufficiently  trained  in  diagnosis  to  be  able  to  recognize  the  early 
symptoms  of  cancer,  or  to  give  proper  instruction  concerning 
it,  this  plan  would  be  all-sufficient  as  a  scheme  for  cancer  edu- 
cation.   But  at  present  such  is  not  the  case. 

When  once  the  medical  profession  has  determined  upon  a 
strictly  practical  fund  of  information;  when  doctors  agree  to 
confine  theoretical  matters  to  their  own  society  meetings,  leav- 
ing all  unsettled  questions  out  of  public  discussion,  whether  in 
lectures  or  articles  for  publication,  then  the  campaign  of  edu- 
cation may  be  conducted  upon  a  rational  and  useful  basis. 
Many  aids  may  then  be  utilized  for  the  dissemination  of  knowl- 
edge, such  as  Young  Men's  and  Young  Women's  Christian 
Associations,  Clubs  of  Trained  ISTurses,  or  Women's  Clubs  of 
any  kind.  These  and  other  similar  organizations  may  become 
avenues  for  spreading  information. 

The  most  important  step  in  this  entire  plan,  however,  is  the 
education  of  the  public  to  the  point  of  undergoing  periodical 
examination,  not  specifically  with  reference  to  this  or  that 
condition,  but  for  a  general  inspection.  If  the  physician  is 
educated  to  make  such  an  investigation  seriously,  and  if  the 
patient  is  taught  to  consider  this  as  the  rational  method  to  be 
pursued  in  health  maintenance,  a  long  stride  will  have  been 
taken  toward  the  prevention  of  many  other  ills,  as  well  as  of 
much  of  the  suffering  which  invariably  ensues  if  the  stage  of 
irremovable  cancer  is  reached. 

Extensive  business  enterprises  and  successful  commercial 
houses  to-day  pay  large  salaries  to  "efficiency  men."  These  are 
experts  who  keep  watch  of  the  general  workings  of  the  busi- 
ness, advising  as  to  the  betterment  of  methods  or  the  avoidance 
of  difficulties.  They  are  often  most  needed  when  those  directly 
interested  are  absorbed  by  what  appears  to  be  a  successful  rush, 
and  are  blind  to  conditions  which  spell  ultimate  disaster.  Hun- 
dreds of  thousands  of  dollars  are  saved  yearly  by  the  employ- 
ment of  such  experts. 

Pine  machinery,  notably  the  automobile,  if  the  best  service 
is  to  be  had  from  it,  is  constantly  subjected  to  careful  inspec- 
tion. The  human  machine  is  far  finer  and  infinitely  more 
delicate;  it  is  constantly  subjected  to  immensely  greater  strain; 
yet  how  few  give  to  it  any  proportion  of  the  care  bestowed  upon_ 
a  motor  car. 

The  teeth  and  the  eyes  are  practically  the  only  parts  of  the 
anatomy  that  receive  adequate   and  regular  attention.      The 


450  THE   CANCER    PROBLEM 

majority  of  people  consult  the  dentist  and  the  oculist  with  a 
commendable  degree  of  system  and  regularity.  But  similar 
attention  is  not  yet  paid  to  the  well-being  of  the  body  as  a 
whole.  Efficiency  physicians  are  needed  to  point  out  wrong 
methods  of  living,  to  warn  when  a  downward  path  is  taken. 
Often  when  the  body  is  seemingly  strong  and  well  and  under 
"full  steam"  so  to  speak,  a  watchful  and  intelligent  eye  will 
foresee  danger  to  which  the  person  absorbed  in  the  pressure  of 
living  is  blind. 

Pending  the  time  when  such  conditions  shall  be  brought  to 
pass,  it  seems  best  that  the  campaign  of  education  against  can- 
cer should  take  note  of  the  following  facts,  and  disseminate 
knowledge  along  the  lines  indicated. 

(1)  That  the  hereditary  and  congenital  acquirement  of  can- 
cer are  subjects  which  require  much  more  study  before  any 
definite  conclusions  can  be  formed  concerning  them,  and  that, 
in  the  light  of  our  present  knowledge,  they  hold  no  special  ele- 
ment of  alarm. 

(2)  That  the  contagiousness  or  infectiousness  of  cancer  is 
far  from  proved,  the  evidence  to  support  this  theory  being  so 
incomplete  and  inconclusive  that  the  public  need  have  no  con- 
cern regarding  it. 

(3)  That  the  public  need  merely  be  instructed  to  apply  to 
cancer  the  same  precautionary  measures  that  should  be  brought 
to  bear  in  the  care  of  any  ulcer  or  open  wound. 

(4)  That  the  danger  of  the  accidental  acquirement  of  cancer 
is  far  less  than  that  from  typhoid  fever,  syphilis,  or  tubercu- 
losis. 

(5)  That  in  the  care  of  cancer  patients  there  is  much  less 
danger  to  the  attendant  from  any  possible  acquirement  of  can- 
cer than  there  is  of  septic  infection,  or  blood  poisoning  from 
pus  organisms. 

(6)  That  the  communication  of  cancer  from  man  to  man  is 
so  rare,  if  it  really  occurs  at  all,  that  it  may  be  practically 
disregarded. 

(7)  That  in  cancer,  as  in  all  other  disease,  attention  to  diet, 
exercise,  and  proper  hygienic  surroundings  is  of  the  utmost 
importance. 

(8)  That  cancer  is  local  in  its  beginning. 

(9)  That,  when  accessible,  it  may,  in  its  incipiency,  be  re- 
moved so  perfectly  by  radical  operation  that  the  chances  are 
overwhelmingly  in  favor  of  its  non-recurrence. 

(10)  That,  when  once  it  has  advanced  beyond  the  stage  of 
cure,  suffering  in  many  cases  may  be  palliated  and  life  pro- 
longed by  surgical  means. 


CAMPAIGN    OF    EDUCATION  451 

(11)  That  while  other  methods  of  treatment  may,  in  some 
cases,  offer  hope  for  the  cancer  victim,  the  evidence  is  con- 
clusive that  surgery,  for  operable  cases,  affords  the  surest 
means  of  cure. 

(12)  That  the  diminution  of  the  risk  of  cancer  by  the  erad- 
ication of  known  predisposing  causes,  or  at  least  of  causes  which, 
from  long  and  varied  experience,  have  come  to  be  accepted  as 
known,  seems  to  be  possible. 

(13)  That  prominent  among  these  predisposing  factors,  for 
which  one  should  be  on  guard,  are :  general  lowered  nutrition ; 
chronic  irritation  and  inflammation ;  repeated  acute  trauma ; 
cicatricial  tissue,  such  as  lupus  and  other  scars,  and  burns; 
benign  tumors — warts,  moles,  nevi  (birth-marks),  etc. 

(14)  That  certain  occupations,  notably  working  in  pitch, 
tar,  paraffin,  or  anilin,  and  with  X-rays,  if  not  safeguarded, 
are  colfducive  to  the  production  of  cancer,  presumably  on  ac- 
count of  the  chronic  irritation  or  inflammation  caused. 

SUMMARY 

The  campaign  of  education  concerning  cancer,  to  be  rational 
and  safe,  must  be  made  to  apply  first  to  the  general  body  of 
the  medical  profession,  and,  through  the  profession,  to  the  pub- 
lic at  large.  It  must  have  for  one  of  its  objects  the  main- 
tenance, upon  the  part  of  the  physician,  of  a  standard  of  ethics 
which  insures  the  best  interest  of  the  patient,  regardless  of 
operative  and  mortality  statistics;  and  the  development,  upon 
the  jiart  of  the  patient,  of  a  spirit  of  confidence  in  and  coopera- 
tion with  the  physician.  It  should  be  aimed  at  health  rather 
than  disease ;  at  physiology  rather  than  at  pathology.  It  must 
be  directed  toward  the  prevention  of  cancer  by  the  maintenance 
of  the  general  health,  as  well  as  toward  the  eradication  of  the 
various  factors,  within  and  without  the  body,  which  are  thought 
to  exercise  a  predisposing  influence  in  the  initiation  of  malig- 
nant disease. 

Such  a  campaign,  intelligently  inaugurated  and  vigorously 
waged,  would  undoubtedly  tend: 

(1)  To  decrease  the  number  of  those  primarily  affected  with 
cancer,  by  modifying  or  eliminating  predisposing  and  precan- 
cerous conditions. 

(2)  To  forestall,  in  large  measure,  the  danger  of  recurrent 
manifestations  because  of  an  awakening  to  the  importance  of 
early  and  radical  removal  of  the  primary  lesion. 

(3)  To  lower  the  mortality  figures,  by  intelligent  attention 
to  precancerous  conditions  and  early  cancerous  affections. 


THE    OUTLOOK 

The  great  advance  in  knowledge  concerning  cancer  made 
during  recent  years  involves  the  elimination  of  a  number  of 
theories  of  the  etiology  of  the  disease. 

Cancer  is  no  longer  to  be  considered  merely  as  the  develop- 
ment of  embryonic  ''rests"  stimulated  to  unfold  their  latent 
powers  of  growth. 

There  are  stronger  reasons  now  than  ever  before  for  abandon- 
ing the  theory  that  cancer  is  a  disease  which  is  directly  com- 
municable by  infection,  and  no  indisputable  evidence  has  been 
offered  to  prove  that  it  is  transmitted  by  an  intermediate  host. 

Much  new  evidence  has  been  advanced  as  to  the  causative 
influence  of  chronic  irritation  in  some  forms  of  cancer.  A  pos- 
sible explanation  of  the  disease  has  been  found  in  the  variations 
to  which  cells  are  liable  in  the  direction  of  losing  their  normal 
differentiation,  and,  more  rarely,  of  acquiring  powers  of  con- 
tinued growth. 

There  is  urgent  need  to  determine  whether  Ehrlich  is  right 
in  assuming  a  peculiar  form  of  immunity — "atreptic  immu- 
nity"— because  of  the  etiological  application  made  of  it.  Ac- 
cording to  this  view,  circumscribed  groups  of  cells  grow,  into 
tumors  because  their  appetite  for  taking  up  food  is  greater  than 
that  of  the  rest  of  the  body. 

It  is  equally  necessary  to  determine  whether  the  workers  of 
the  Imperial  Cancer  Research  Fund  are  right  in  denying  the 
existence  of  atreptic  immunity,  their  conclusions,  likewise,  hav- 
ing important  etiological  bearings  in  that  they  appear  to  have 
revealed  the  fact  that  continuous  growth  results  as  a  conse- 
quence of  a  loss  of  power  of  cells  to  control  their  own  growth, 
or  to  call  forth  resistance  to  growth.  This  point  is  of  the  utmost 
importance,  since  its  firm  establishment  would  eliminate  the 
whole  group  of  etiological  and  working  hypotheses  which  seek 
for  the  cause  of  cancer  in  stimulus  to  development. 

The  whole  trend  of  investigation  points  not  to  a  single  cause, 
but  to  a  number  of  causes  of  cancer.  There  is  reason,  too,  for 
the  belief  that  the  disease  to  which  the  term  cancer  is  applied  is 
still  a  composite,  despite  the  fact  that  syphilis,  tuberculosis, 

452 


THE    OUTLOOK  453 

actinomycosis,  blastomycetes,  and  even  leprosy,  which  were  for- 
merly confused  with  cancer,  are  now  known  to  be  separate  enti- 
ties, each  with  its  specific  cause.  Who  can  tell  to  what  further 
extent  this  process  of  differentiation  and  isolation  may  lead? 
The  time  may  come  when  carcinoma  and  sarcoma  will  be  sep- 
arated into  diseases  undeniably  distinct  one  from  the  other. 

While  this  complexity  of  etiology  remains  unsolved,  the  pre- 
vention of  cancer  cannot  become  a  truly  practical  problem,  and 
the  only  methods  which  can  be  recommended  with  reasonable 
likelihood  of  diminishing  the  prevalence  of  cancer  are  measures 
which  have  for  their  purpose  the  elimination  or  avoidance  of  all 
forms  of  chronic  irritation. 

From  the  moment  it  was  recognized  that  chronic  irritation 
and  acute  trauma  may  induce  cancer,  it  was  inevitable  that  a 
large  field  for  dispute  would  be  opened  in  connection  with  acci- 
dental injuries,  negligent  litigation,  workingmen's  compensation 
acts  and  insurance,  and  similar  matters.  Whether  injury  has 
or  has  not  caused  cancer  in  a  given  case  is,  of  course,  primarily 
a  medical  and  not  a  legal  question.  Yet,  inasmuch  as  a  second- 
ary legal  aspect  may  arise,  both  science  and  common  sense  re- 
quire that  rational  criteria  be  fixed  for  determining  whether  a 
cancerous  condition  has  been  caused  or  induced  or  superinduced 
by  an  earlier  irritation,  by  trauma,  or  by  other  injury.  The 
elucidation  of  this  phase  of  the  problem  furnishes,  therefore,  an 
important  field  of  research  for  the  future. 

Pending  the  time  when  the  cause  or  causes  of  cancer  shall 
have  been  discovered,  and  when  it  will  be  possible  to  cure  the 
disease  by  other  means  than  by  surgical  removal,  what  is  the 
outlook  for  the  cancer  problem  and  the  cancer  patient  ?  In  the 
light  of  modern  cancer  research  is  the  prospect  for  the  solution 
of  the  problem  a  hopeful  one  ?  Are  we  justified  in  encouraging 
the  belief  that  the  outlook  for  the  patient  is  less  despairing 
than  formerly? 

The  study  of  the  various  phases  of  the  cancer  problem  which 
are  outlined  in  the  preceding  pages  must  convince  everyone 
that  the  concentrated  effort  of  so  many  earnest  and  intelligent 
investigators  is  slowly  but  surely  clearing  away  much  of  the 
mystery  which  for  centuries  has  obscured  the  questions  of  the 
initiation  and  the  progress  of  the  disease. 

With  the  careful  clinical  and  laboratory  examinations  to 
which  we  now  know  all  patients  should  be  subjected  when  they 
present  themselves  for  treatment,  there  is  justification  for  the 
belief  that  in  future  a  progressively  smaller  and  smaller  propor- 
tion of  cases  of  cancer  will  be  wrongly  diagnosed,  and  conse- 
quently wrongly  treated. 


454  THE    OUTLOOK 

With  the  campaign  of  education  directed  against  the  neglect 
of  the  many  small  things  which  may  lead  to  the  graver  condi- 
tion known  as  cancer ;  with  the  increasing  mastery  of  the  pre- 
disposing causes  of  the  disease,  and  with  the  greater  willingness 
on  the  part  of  individual  patients  to  present  themselves  for 
surgical  treatment  for  its  early  manifestations,  there  is  hope 
that  the  future  will  be  marked  by  a  progressive  decrease  in  the 
number  of  persons  who  come  within  the  category  of  those  having 
inoperable  and  irremovable  cancer. 

With  the  perfection  of  surgical  technic  which  characterizes 
modern  practice,  and  with  the  intelligent  utilization  of  the  vari- 
ous adjuvant  methods  and  measures  which  may  be  employed  to 
alleviate  suffering,  the  lot  of  those  who  are  no  longer  amenable 
to  surgical  cure  is  certainly  far  less  miserable  and  hopeless  than 
was  that  of  persons  similarly  afflicted  even  a  decade  or  two  ago. 

While  it  cannot  be  gainsaid  that  the  cancer  problem  to-day  is 
still  fraught  with  perplexity  and  uncertainty,  one  indisputable 
fact  stands  out  in  bold  relief,  serving  as  both  guide-post  and 
danger-signal  for  the  present  and  the  future — //  cancer  cells  he 
cut  out  soon  enough  a  permanent  cure  is  effected!  This  alone 
is  sufficient  to  warrant  the  statement  that  we  are  "travelling 
hopefully !" 


GENERAL    BIBLIOGRAPHY 


No  attempt  is  made  to  give  a  complete  bibliography  of  any  subject  in 
the  table  of  contents.  The  literature  of  cancer  is  so  voluminous  that  it 
is  neither  available  nor  dependable  in  its  entirety.  For  this  reason  it 
has  seemed  expedient  to  correlate  a  selected  list  of  contributions  con- 
cerning the  different  phases  of  the  cancer  problem,  and  to  cite  articles 
and  volumes  which  contain  full  and  valuable  lists  of  references. 

Inasmuch  as  certain  subjects  overlap,  to  a  greater  or  less  extent,  refer- 
ances  concerning  these  are  given  without  differentiation.  Other  subjects 
are  individually  considered. 

References  under  each  subdivision  are  arranged  in  alphabetical  se- 
quence of  authors'  names. 

HISTORY 

(1)  Ancient 

(2)  Modern  Cancer  Research 

Albert,  Aaron.— DE  DIAGNOSI  MORBORUM  MAMM^.     Gryphise, 

F.  G.  Kunike,  1857. 
Alberts,    J.    E. — "Over   Kanker.      Historiseh-critiseh    en    experimental 

Onderzook."     Groningen,  1885. 
Alberts,  J.  E. — "Das  Carcinom  in  historischer  und  experimentell-patho- 

logischer  Beziehung."    Jena,  1887. 
':Annis,  E.  J. — "Cancer;  A  Brief  History,  with  some  Remarks  on  the 

Prophylaxis   of  Cancer  of  the  Digestive  Organs,"  Am.  Jour,  of 
.    Gastro-Enterology,  1911-1912,  i,  p.  1. 
Barduzzi. — Sui  Codicici  e  sulle  edizione  del  libro  "De  re  Medica"  di 

Aulo  Cornelio  Celso :  Riv.  di  storia  crit.  d.  sc.  Med.  e  Nat.    Faenza, 

1910,  i,  11-13. 
Bashford,  E.  F. — Verhandlung  des  Komitees  fiir  Krebsforschung,  Hft. 

iii,  1903-4,  reprinted  from  Deut.  med.  WocJi..  1904;  First  Annual 

Report,  Imperial  Cancer  Research  Fund,  1903;  Second  Scientific 

Report,  Imperial  Cancer  Research  Fund,  Part  I.  1905,  etc. 
Bashford,  E.  F. — "The  Obligation  Imposed  on  the  General  Practitioner 

by  the  Development  of  the  Experimental  Investigation  of  Cancer." 

The  Practitioner,  1911,  Vol.  LXXVI,  p.  337. 
Baudouin. — "La  derniere  maladie  de  Napoleon  I,"  Gaz.  med.  de  Paris, 

Mar.  18,  1901. 
"Cancer  Cures  in  the  18th  Century,"  Brit.  Med.  Jour.,  1905,  ii,  p.  56. 
Coupland,    Sidney. — The   Cancer   Charity  of  the   Middlesex   Hospital, 

1792-1902,  Reports  from  the  Cancer  Research  Laboratories  of  the 

Middlesex  Hospital,  Vol.  I,  London,  1902,  p.  1. 
Editorial,  Brit.  Med.  Jour.,  October  22,  1910,  p.  1266. 
Editorial,  The  Practitioner,  April,  1899,  p.  362. 

455 


456  (EXERAL    BIBLIOGRAPHY 

Ewing,  James. — "The  Cancer  Research  Hospital."  New  York  Med. 
Jour.,  December  27,  1913,  p.  1241. 

Justaniond,  J.  0. — *'An  Account  of  the  Methods  Pursued  in  the  Treat- 
ment of  c'ancerous  and  Scirrhous  Disordere  and  Other  Indurations/' 
1S70. 

Klein. — "Zur  Gesehiehte  des  Krebses,"  Arch.  f.  ijhys-diatet.  Therapie, 
Berl.,  inOl.  vi.  44-74. 

Landau,  R. — "Die  altesten  medizinischen  Drueke;  eine  biblioerraphische 
Studie,"  Mitt.  z.  Geschich.  d.  Med.  u.  d.  Naturw.,  Hamb.  u.  Leipz., 
1904,  iii,  246-259. 

Ledoux-Lebard,  R. — "Documents  pour  serv'ir  a  I'etude  du  charlatanisme 
du  cancer  au  XVIIIeme  siecle,"  Bull,  de  I'assoe.  frang.  pour.  I'etude 
du  cancer,  Paris,  1911,  iv,  383-413. 

Licht,  H. — "I'^eber  Gesehiehte  und  Entwicklungsgeschichte  des  Car- 
cinoms,"  Wiirzburg,  1891. 

Mackenzie,  Sir  Morell.— "The  Fatal  Illness  of  Frederick  the  Noble," 
London,  1888. 

Mamlock,  G.  L. — "Krebsforschung  im  Zeitalter  der  Aufklarung,"  Zschr. 
f.  klin.  Med.,  1904,  Hi,  p.  178. 

Menetrier,  P.— "Cancer,"  Paris,  1908. 

Meunier. — "Coelius  Aurelianus;  maladies  aigues  et  maladies  chroniques; 
le  methodisme,"  Janus,  Harlem,  1906,  xl,  129. 

Meunier,  L. — "Histoire  de  la  Medecine  Depuis  ses  origines  jusqu'  a  nos 
joui's.  Preface  par  le  Professeur  Gilbert  Ballet,  President  de  la 
Soc.  fran?.  d'Histoire  de  la  Medecine."     Paris.     1911, 

Mitchell,  R. — "A  General  and  Historical  Treatise  on  Cancer  Life;  Its 
Causes,  ProgTess,  and  Treatment,"  London,  1879. 

Muir,  John. — "The  Cancer  Curer  in  South  Africa,"  South  Africa  Medi- 
cal Record,  Jan.  25,  1906,  p.  5. 

Mumford,  James  G. — "Studies  in  Cancer — Historical  and  Critical," 
Annals  of  Surgery,  January,  1909. 

Orth,  J. — "Ueber  die  Krebsgeschwulst  des  Menschen,"  Berlin,  1909.  G. 
Reimer,  p.  107-125. 

Paget,  Sir  James. — "Lectures  on  Surgical  Pathology,"  London,  1853. 

Paget,  Sir  James. — The  Morton  Lecture  on  Cancer  and  Cancerous  Dis- 
eases. Lancet,  November  19,  1887. 

Park,  Roswell. — "A  Further  Inquiry  into  the  Frequency  and  Nature  of 
Cancer,"  The  Practitioner,  1899,  Vol.  LXII,  April,' p.  385. 

Pemberton,  0. — "Obseivations  on  the  History,  Pathology,  and  Treat- 
ment of  Cancerous  Diseases,"  London,  1858. 

Peyrilhe,  B. — "A  Dissertation  on  Cancerous  Diseases,"  Trans,  from  the 
Latin,  with  notes,  London,  1771. 

Protocol  of  the  Meeting  for  the  Organization  of  the  International  Asso- 
ciation for  Cancer  Research — Saturday,  May  23,  1908 :  Cancer. 
Internat.  Monatschr.,  etc.,  Berl.,  1908-9,  38,  78. 

Quadrio,  Giuseppe  Maria. — "Nuovo  methodo  por  curare  ogni  canchero 
coperto  e  specialmente  le  ghiande  delle  Mamelle,  e  di  altre  parti 
del  coT\)o,"  Venezia,  1750. 

Sandwith,  F.  M.— "A  Brief  History  of  Cancer,"  The  Clin.  Jour.,  Lond., 
1909-10,  XXXV,  p.  360. 

Sandwith,  F.  M. — "Two  Historical  Cases  of  Cancer,  and  the  Treatment 
of  the  Disease,"  The  Clin.  Jour.,  Lond.,  April  13,  1910. 

Sydenham. — "Observations  on  the  History  and  Cure  of  Acute  Diseases." 
(Revised,  etc.,  by  John  Swan,  M.D.",  MDCCXLIX.) 

Virchow,  Rudolph. — "Die  Kranhafte  Geschwiilste,"  Onkologie,  1863-65. 


GENERAL    BIBLIOGRAPHY  '  457 

Vaughan,  J.  W. — ''Some  Modera  Ideas  of  Cancer,"  Jour.  Am.  Med. 
Assn.,  1910,  liv,  p.  1510. 

Walshe,  Walter  Hayle. — "The  Nature  and  Treatment  of  Cancer,"  Lon- 
don, 1846. 

Wolff,  Jacob. — "Die  Lehre  von  der  Krebskrankheit  von  den  'altesten 
Zeiten  bis  zur  Gegenwart,'  "  Part  I,  1907;  Part  II,  1911,  Jena,  1911. 

GENERAL   DISTRIBUTION 

(1)  Botanical 

(2)  Zoological 

(3)  Geographical  and   Ethnological — Statistical  Considerations — 

Site-incidence 

Botanical 

Heeke,  L. — "Der  'Krebs'  der  Pflanzen,"  Wien.  klin.  Woch.,  1912,  xxv, 
229-231. 

Hutchinson,  J. — "Does  Cancer  Occur  in  Vegetables'?"  Lancet,  Lond., 
1912,  i,  756. 

Jensen,  C.  0. — Von  Echten  Geschwiilsten  bei  Pflanzen.  Travaux  de  la 
2eme  Conference  Internationale  pour  I'etude  du  cancer,  1910,  Paris, 
1911,  p.  243. 

Noel,  L. — Sur  la  topographie  et  la  contagion  du  cancer,  Bev.  des  mala- 
dies cancereuses,  Paris,  1896-1897,  ii,  pp.  137,  201;  also  These  de 
Paris,  1897. 

Packard,  Horace. — "Tree  Cancer.  A  Striking  Analogy  between  Certain 
Vegetable  Tumors  and  Malignant  Animal  Tumors,"  Boston  Med. 
and  Surg.  Jour.,  1911,  Vol.  CLXV,  p.  247. 

Penhallow,  D.  P. — "A  Birch  Rope.  An  Account  of  a  Remarkable  Tu- 
mor Growing  upon  the  White  Birch."  Trans.  Roy.  Soc.  of  Can- 
ada, 1906,  2^s,     Vol.  XII,  Pt.  I,  See.  4,  pp.  239-255. 

Potebnia,  A. — "Ein  neuer  Krebserreger  des  Apfelbaumes,  Phacidiella 
discolor  (Mout  et  Sacc.)  A.  Pot.,  seine  Morphologie  und  Ent- 
wicklung-sgeschichte,"  Ztschr.  f.  Pflanzenkr.,  Stuttg.,  1912,  xxii, 
129-148.     3  pis. 

Smith,  E.  F.— "The  Etiology  of  Plant  Tumors,"  Science,  New  York, 
and  Lancaster,  Pa.,  1909,  n.  s.,  xxx,  223. 

Smith,  E.  F. — The  Structure  and  Development  of  Crown-Gall :  A  Plant 
Cancer,  U.  S.  Department  of  Agriculture,  Bureau  of  Plant  In- 
dustry, Bull.  No.  255,  June  29,  1912. 

Smith,  E.  F. — "Pflanzenkrebs  versus  Menschenkrebs,"  Centralbl.  f. 
Bakteriol.,  etc.,  Jena,  1912,  xxxiv,  2  Abt.,  394-406. 

Smith,  Erwin  F.  (U.  S.  Dept.  Agr.,  Washington,  D.  C.)..— "Cancer  in 
Plants":  17th  Int.  Cong,  of  Medicine,  London,  1913,  Sect.  Ill, 
Genl.  Pathology  and  Pathol.  Anat.— Independent  Paper,  p.  281. 

von  Tubeuf,  Karl,  Freiherr. — "Diseases  of  Plants  induced  by  cryptoga- 
mic  parasites :  Introduction  to  the  Study  of  pathogenic  Fungi,  slime 
fungi,  bacteria,  and  algae,"  English  edition  by  William  G.  Smith, 
Lond.,  1897. 

von  Tubeuf,  Karl,  and  Smith,  William  G. — "  'Witches  brooms,'  due  to 
^cidium  elatinum,"  Diseases  of  Plants,  1897,  pp.  18,  24,  72,  88, 
404,  410. 

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zu  Gallensteinen  und  Galleiisteinnarben,"  Deulsch.  Arch.  f.   klin. 

Med.,  Leipz.,  1S88-9,  xliv,  150-184. 
Zimmer,  A. — ''Soil  die  anatomische  Form  eines  Rektnmcarcinoms  be- 

stimmend  sein  fiir  seine  Oi:)ei'abilitat?"   Wien.  Jdin.  Woch.,  1909, 

No.  35. 

CLINICAL   COURSE 
(including  spontaneous  cure) 

DIAGNOSIS— POSSIBLE   ERRORS   IN   DIAGNOSIS 

Abderhalden,  E.,  und  Suwa,  A. — "Weiterer  Beitrag  zur  Kenntnis  der 
bei  partiellen  Hydrolyse  von  Proteinen  auftretende  Spaltprodukte," 
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Abderhalden,  E.,  und  Pineussohn,  L. — "Zur  Kenntnis  der  peptolytisehe 
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Abderhalden,  E. — "Weiterer  Beitrag  zur  Kenntnis  der  beider  partiellen 
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peptolytischer  Fennente  in  Tier  und  Pflanzengeweben,"  ibid., 
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Abderhalden,  E. — "Neue  Forsehungsrichtungen  auf  dem  Gebiete  der 
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Aehard,  Ch.,  Benard,  Heni'i,  et  Gagneux,  Ch. — "Leucodiagnostique  du 
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Bainbridge,  W.  S. — "Three  Unique  Head  Tumors:  I.  Indurated  Mass 
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Bainbxidge,  W.  S. — "Possible  EiTors  in  the  Diagnosis  of  Abdominal 
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Barrett,  C. — "Ueber  Komplementablenkung  bei  Menschenearcinom," 
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Beatson,  (Sir)  George  Thomas. — "Local  Recun-ence  after  Removal  as  a 
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Beatson  (Sir)  George  Thomas. — "Splenic  Metastasis  in  a  Case  of  Car- 
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484  GENERAL    BIBLIOGRAPHY 

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486  GENERAL    BIBLIOGRAPHY 

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PROPHYLAXIS— CAMPAIGN    OF    EDUCATION 

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EdiJ:orial  (The  Enzvme  Treatment),  Brit.  Med.  Jour.,  July  24,  1909, 
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tine as  a  reputed  remedy  for  Cancer  of  the  female  genital  organs, 
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Kennedy,  Saml. — "Is  Cancer  curable?  The  cancer  controversy:  Mattei 
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Kolb,  K. — "Ein  Beitrag  zu  den  Misserfolgen  mit  Antimeristem  (Can- 
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More  Secret  Remedies.  What  they  cost  and  what  they  contain.  Based 
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"Mrs.  Van  Niekirk's  Cancer  Cure :  The  Report  of  the  Select  Committee 
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GENERAL    BIBLIOGRAPHY  489 

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p.  649. 

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With  special  plate. 


NON-SURGICAL   TREATMENT 

(1)  Caustics    or    Eseharoties 

(2)  Physiotherapy 

(3)  Biotherapy 

(4)  Miscellaneous  Agents 

Caustics  or  Escharotics — Miscellaneous  Agents 

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465. 


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Bumm,  E,,  und  Voigt,  H. — "Zur  Technik  der  Carcinombestrahlung," 
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492  GENERAL    BIBLIOGRAPHY 

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of  erysipelas  and  Bacillus  prodigiosus;  no  recun'ence  after  9% 
yeai-s,"  Ann.  Surg.,  Phila.,  1912,  Iri,  787. 

Coley,  W.  B. — "Contribution  to  the  Study  of  Sarcoma  of  the  Femur. 
Apparent  cure  by  the  mixed  toxins  of  erysipelas  and  Bacillus  pro- 
digiosus; well  lOYz  years  when  a  malignant  tumor  (sarcoma  and 
epithelioma)  developed  in  the  thigh  at  the  site  of  an  old  X-ray 
dermatitis,"  Ann.  Surg.,  Phila.,  1913,  Iviii,  p.  97. 

Coley,  W. 'B. — "Sarcoma  of  the  humerus,"  Am.  Surg.,  Phila.,  1911,  liii, 
286-288;  "A  round-celled  sarcoma  of  the  femur  involving  two- 
thirds  of  the  shaft  with  extensive  pectoral  and  abdominal  metas- 
tases, well  81/^  years  after  treatment,"  Ibid.,  288-290 ;  "Large  inop- 
erable recurrent  intra-abdominal  sarcoma  following  removal  of  a 
round-celled  sarcoma  of  the  testis  a  year  before;  disappearance 
under  mixed  toxins  of  erj'sipelas  and  Bacillus  prodigiosus,"  Ibid,, 
299. 

Coley,  W.  B. — "A  Report  of  recent  cases  of  inoperable  sarcoma  success- 
fully treated  with  mixed  toxins  of  eiysipelas  and  Bacillus  prodigio- 
sus," Surg.  Gynec.  and  Obst.,  Chicago,  1911,  xiii,  174-190. 

Coley,  W.  B. — "Inoperable  sarcoma  of  the  scapula  in  an  infant  two 
months  old  successfully  treated  with  the  mixed  toxins  of  erysipelas 
and  Bacillus  prodigiosus,"  Am.  Surg.,  Phila.,  1911,  liii,  844. 

Coley,  W.  B. — "A  plea  for  more  conservative  treatment  of  sarcoma 
of  the  long  bones,"  Jour.  Am.  Med.  Assn.,  Chicago,  1910,  liv,  333- 
343. 

Coley,  W.  B. — "The  treatment  of  inoperable  sarcoma  with  bacterial 


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•'500  GENERAL    BIBLIOGRAPHY 

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Handley,  W.  Sampson. — "Microscopical  Study  of  the  Parietal  Dissemi- 
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Handley,  W.  Sampson. — "On  Lymphatic  Permeation  as  a  Factor  in  the 
Dissemination  of  Melanotic  Sarcoma,  with  a  Note  on  the  Operative 
Treatment,"  Archives  of  Middlesex  Hosp.,  Vol.  VII,  Fifth  Report 
Cancer  Res.  Laboratories,  1906,  p.  52. 

Handley,  W.  Sampson. — "On  Lymphatic  Permeation  as  a  Factor  in  the 
Dissemination  of  Melanotic  Sarcoma,  with  a  Note  on  Operative 
Treatment,"  Archives  of  Middlesex  Hosp.,  1908,  vii,  p.  52. 

Handley,  W.  Sampson. — "A  New  Method  for  the  Relief  of  the  Brawny 
Arm  of  Breast  Cancer  and  for  Similar  Conditions  of  Lymphatic 
CEdema,"  The  Lancet,  Lond.,  Mar.  14,  1908,  p.  783;  also.  Arch. 
Middlesex  Hosp.,  Vol.  12,  p.  28. 

Handley,  W.  Sampson. — "A  New  Method  for  the  Relief  of  the  Brawny 
Arm  of  Breast  Cancer  and  for  Similar  Conditions  of  Lymphatic 
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Lymphatic  System,"  Brit.  Med.  Jour.,  1910,  i,  683,  abstr.  Lancet, 
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Handley,  W.  Sampson. — "Recent  Advances  in  the  Surgical  Treatment 
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Hartmann,  H.,  et  Fredet,  P. — "Resultats  eloignes  de  ligatures  atrophi- 


504  GENERAL    BIBLIOGRAPHY 

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Ann.  de  Gyn.  et  d'Obst.,  Par.,  1898,  xlix,  110-129. 
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506  GENERAL    BIBLIOGRAPHY 

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INDEX  OF  AUTHORS 


Abbe.    Robert,    298 
Abderhalden,   193.   194 
Abraham,    Max,    303 
Acton,    H.    W.,    367 
Adami,     I.     George,     116, 

131,    155 
Adams,  George,  287,  292, 

297 
Albrecht,  124 
AlthofE,  7,  8 
Aly,    255 
Am-Ende,  331 
Antal,  383 
Anton,    370 
Apolant,  H.,  27,  124,  149, 

152,  155,  162,  164, 
177,    178 

d'Arsonval,    316 
Ascoli,   193 
Asher,    152 

Babcock,   W.   W.,   341 

Bainbridge,  William  Sea- 
man, 30,  201,  212, 
214,  215,  232,  242, 
243,  343,  353,  364, 
369,  385,  393,  428 

Ballard,  Cora  M.,  206 

Barclay,  295 

Barlow.  See  Lazarus- 
Barlow. 

Barnato,  Barney,  15,  431 

Barrett,   C,  209 

Bashford,  E.  F.,  9,  10, 
11,  17,  25,  29,  33, 
36,  47,  48,  50,  56, 
57,  62,  67,  74,  76, 
77,  79.  82,  84.  86, 
90,  98,  101,  102, 
117,  125,  126,  133, 
146,  149,  150,  152, 

153,  155,  161,  162, 
172,  177,  179,  195, 
337 

Baumgartner,  383 

Beadles,    227 

Beard,     John,    240,    242- 

250,    426 
Beatson,  392 
B^clfere,  298 
Becquerel,  297,  318 
Bell,   Sir  C,  282 
Benecke,  116 
Bergell,    P.,    343 
Berger,   332 

von    Bergmann,   365,   373 
Bergonie,  317 
Betton-Massey.    See  Mas- 

sey 
Bevan,  342 
Bie,  v.,  288,  289 
Bier,   373 
Birchmore,  54 
Bland-Sutton,  44,   54,  55, 

185 
Bloodgood,   J.   C,   223 
Blumenthal,   F.,    26,   328, 

338 


Boas,  227,  365 
Boldt,   H.  J.,  448 
Bolingbroke,  Lord,  3 
Borrel,    26,  27,   123,   151, 

152,  153,  157 
Borst,    130,   132 
Bowen,   25 
V.  Branmian,  370 
Branstein,   298 
von    Brendt,   320 
Bridr6,   27 
Brieger,  192 
Broadbent,  282 
Broca,    373 
Brodie,      Sir      Benjamin, 

110,  446.  447 
Brooks,  Harlow,  53 
Brown,  Mary   Hess,   268 
Bruns,   334 
Bryant,  J.   D.,  375 
Bulkley,  L.  Duncan,  201 
Bull,  William  T.,  335 
Bullock,    25 
Bumm,  E.,   305 
Burgsdorf,  V.,  290 
Busch,   W.,  334 
Butlin,  Sir  Henry  T.,  81, 

85,    98,    127.    133, 

134,    440 
Byrne,     John,     306,     307, 

308,  388,  393 
Bythell,    295 

Caan,    209,    304 

Calkins,    G.,    43 

Cantier,   P.,  384 

Carnot,   343 

Cathcart,  C.  W.,  185 

Cazenove,  333 

Cerny.  284 

Cheatle,    Lenthal,   364 

Cheron,    318 

Choyce,  C.  C,  101 

Clark,    William    L.,    322, 

323 
Clay,  J.,  257,  258 
Clowes,   56 
Cluna,  282 

Clunet,   J.,   160,   293,  294 
Coca,     Arthur     F..     328, 

330.   338.  339.   340 
Cohnheim,     27,    44.     113, 

114 
Cole,  L.  G.,  207,  208 
Coley,    W.    B.,    295.    329, 

333,  334,  335,  337 
Collinge,  Walter  E.,  59 
Compton,   25 
Coolidge,  W.   D.,  294 
Cooper,  Sir  Astley,  373 
Copeman,   25 
Cornil,   116,  155 
Councilman.   W.   T.,   222 
Coupland,  Sidney,  13,  15, 

16 
Cramer,  25,  172 
Crile,    220 
Cripps,  Harrison,  98,  365 

509 


Culpepper,    Nicholas,    260 
Curie,   Mme.,  297 
Curtis,  B.  T.,  336 
Cushing,   Harvey,  370 
Czerny,    10,    11,    25,    28, 

29.    242,   304.   315, 

325 

Da  Fano,  25 
Dalrymple,  373 
Danlos,    H.,    298 
Darier,  298 
Darwin,    154 

Davidson,  Mackenzie,  298 
Davis,  J.  A.,  271-274 
Dawbarn,    Robert   H.    M.. 

.374-381,    384.    420 
Degrais,    297,    298,    299, 

303 
Delbet,   303 
Demarquay,   373 
Depage,    360 
Dfepres,  334 
Desplat,   311 
Diesing,   343 
Dijkman,  B.  J.,  2 
Dominici,     M.     H.,     299, 

300.  303.  318 
Dorrance,    339 
Dorsett,    383 
Doyen,  31,  256,  257,  317, 

321,  322,  329,  330, 

331,  332 
Dubois-Crepagne,  311 
von  Duehrrsen,  447 
von     Dungern.     28,     193, 

194,   338 

Eberth,  55 
Edling,    L.,    302 
Bhrenreich,   54 
Ehrlich,  27,  29,  124,  125, 

146,  150,  152,  154, 

161,  162,  164,  177, 

178.  329 
Elsberg.  365 
Elser,   William,   199 
Emmerich,   329,   332,   334 
English,   T.    Crisp,   369 
Eve,     Sir     Frederic,     96, 

337,   367 
Ewald,   227 
Ewing,     James,     6.     155, 

199,  332,  338,  343 
Exner,  298,   300 

Fairchild  B.  T.,  247 
Falk,  B.,  343 
Farmer,   117,   125 
Fehleisen,   333.   384,  335 
Fibiger.  J..  123,  153,  160 
Mchera,     G.,     330,     340, 

341 
Field,  Eva  H.,  51 
Finsen,  N.  R.,  289.  290 
Finzi,    N.     S.,    300,    301, 

302 
Fischer,  Emil,  27 


510 


INDEX 


Floniraing,   55 
i'oerstor.   A.,  209 
Follard,  298 
Foote,  E.  M.,  312 
Forster,    S 
Foulerton,  29 
Fox.   F.  J.,  209 
Frederick,      Carlton      C, 

307,  308 
Fredet,  384,  385 
Frcund,  193 
Fritsch,   383 
Frohner,  50 
Fuchs.  284 
Fuhs,  192     ■ 

Gastpar,   93 

Gay,   Frederick  P.,  338 

Gaylord,     Harvey    R.,     5, 

50.     57,     58,     152, 

172 
Geets,   330 
Gerhartz,   318 
Gerster,  A.  G.,  336 
von   Gierke,   25 
Gilman,     328,     330,     338, 

340 
Gilruth,   55.  57 
Gould,  Sir  Alfred  Pearce, 

296,   305,  424,   427 
Greenwald,  192 
Guyon,  375 
Gwyer,     Frederick,     331, 

343 

Haaland,     25,     27,     125, 

151,   152,   153.   155 
Hahn,    155,   304 
Hake,   25 

Halsted,   352.    359,  363 
von    Hansemann.     David, 

9,  116,  154,   155 
Hanau,  A.,   150 
Handley,      W.      Sampson, 

140,  347,  356,  359, 

360,  361,  362,  363, 

364.  366,  367,  368, 

371 
Hanow,  384 
Harris.  William.  75 
Harrison,    A.    G.,    54 
de  Keating  Hart,  31,  310, 

316,  317,  319,  320, 

393 
Hartmann.  384 
Harvey,  372 
Hastings,   303 
Hansen,    227 
Hauser,    Gustav,   115 
Haviland,  61 
Hedges,   Ellis,   217 
Heidenhain,       357.       358, 

360,  362 
Henson.   W.   Warner,   226 
Herrenschmidt,   303 
Hess,   192 
His,    138 
Hodenpyl,   330,   341,   342, 

343 
Hoffman,     Frederick     L., 

66,    91 
Hofmeir,   383 
Hofineister.  23 
Holzknecht.    300 
Hopkins,  John,  266 
Horsele.v,    370 
Hughes,   Henry.  213 
Hulke,   257,    258 
Hunter,    John,    106 
Hutchinson,  Woods,  51 
Hyde,  James  N.,  290 


Jaboulay.   55 

Jacob,    330 

von  Jaksch,  334 

Janeway,   H.   H.,  200 

Jeflfrics,   E.   M.,   199 

Jensen,    26,    42,    43,    150, 

255 
Jesionek,   291 
Jessup,    D.    S.   D.,    218 
Johannsen,   253,    255 
Johnson,    Josse.    252 
Johnson,   Raymond,  101 
Jonasson,    68 
Jones,  Henry  Lewis.  296 
Jonnosco,    3S4.    385 
Justamond,   107 

Kaldeck,    192 
Kaminer,    193 
Kassabian,   M.   K.,    295 
Kaufman.   L.   R..  206 
Keating-Hart.     See  Hart. 
Keen,  W.   W.,  222 
Kelly,   383 
Kemp,    205,   215 
Kennedy,   S.,   261 
King,   George,    83,    85,   90 
Kirchner,    Professor,    7 
Klebs,  E.,  116 
Klemperer,     George,      26, 

152 
Kloninger,    330,    343 
Koch,  M.,  55,  152 
Koenig,    373 
Koyo,   192 
Kolb.    K.,    253 
Kolle,  152,  162,  177 
Kraus.   193 
Krylov.   298 
Kummel,  255 

Lambert,  Robert,  308 
Lane,  Sir  Arbuthnot,  444 
Lange,    372 
Langham.    357 
Lassar,   298 
Latham,  A.,  369 
Lawrence,   F.   W.   P.,   101 
Lazarus-Barlow,    15,     68, 

69.    126,    153,    303 
Lebert.   227 
Lebredo.   339 
Ledoux-Lebard,   302 
Leidy,    59 

Lewin,  C.  26.  152,  343 
von  Leyden,   E.,  7,  8,  26, 

122,  328,  338,  343 
Lintz,   192 
Lipps,  374,  375 
Loeb,    Leo,    52,    152,    308 
Loeffler,  331 
Loveland,  John  E.,  399 
Lucas-Champonni&re,   332 

MacCormac,  303 
Macewen,  370 
MacFadyean,     Sir     John, 

47 
Mackay,  Charles  Gordon, 

341 
Mackee,   George  M.,   295 
Mackenzie,     Sir     Morell, 

266 
McCastline,  Henry.  212 
McConnell,     Guthrie,     74, 

75,  76.  91 
McCosh,    Andrew    J.,    231 
Madden,  371 
Madelung.   374,  375 
MKfeondie,   373 
Magiath,   G.   B.,   222 


Maisonneuve,  375 

Malpighi,  43 

Mamlock,    255 

Marchand.    110 

Marie,  293,  294 

Marine,    David,    57 

Martel.    299 

Martin,  384 

Massey.    G.    Betton,    308, 

323,    388 
Mattel,    Cajsar,   261 
Matzenstauiu,    298 
Mauclaire,  373,  375 
Maunoir,  373 
Mavo,    215,    227 
Mayo.  Charles  H.,  361 
Medigrcceanu,   25 
Mever,   George,   7 
Mever,   Willy,  373 
Mlchaelis,  L.,  26,  54,  157 
Middledorpf,   306 
Midowski,  227 
Miles,  Ernest  W.,  365 
Mirault,   373 
Monsarrat.   K.  W.,   366 
Morau.   H.,   150 
Moreschi,   27 
Morestin.   384 
De      Morgan,      Campbell, 

110,   142,   158,   282 
Morgan,  David  J.,  257 
Moore,     Benjamin,      117, 

125 
Moore,  C.    H.,    110,    142, 

158,   279.   280,   283 
Morris,    Sir    Henry,    243, 

417 
Morris.    Sir  Malcolm,    11, 

12,   13.    297 
Morton,  W.  J.,  249 
Mosher.  Eliza.  214 
Moullln,   Mansell,  337 
Movnihan,    160,    227 
Mulr.   J..   2,   3 
Muller.  Johannes.  138 
Munro,   Alexander,   106 
Murachi,   192 
Murrav,  J.  A.,  25,  47,  48, 
■55,  57,  76,  77,   79. 

86,    99,    102,    117. 

125,  133,  146,  150, 

151,  155,  172 
Murphy,    I.    B.,    125 
Murphy,    J.    B,.    363,    364 
Muvs,   Johan.  372 
Myler,  J.  W.  Glenton,  252 

Nagelschmidt,     31.     317, 

320,  321 
Neve,   E.   F.,   67 
Newmark,  L,,  209 
Newsholme,     Arthur,    80, 

88,   84,  85.  90 
Nichols,    41 
Nicholson,  346,  347 
NSel,    L.,    40 

Oertel,    74,    117 
Oestreich,  331 
Ordway,  Thomas,  7 
Orth,    J.,    158 

Packard.    John    H.,    373, 

387 
Paget,  Lady,  261-264,  266 
Paget,      Sir     James.     98, 

108,  110,  142,  183, 

280 
Paget,  Stephen,  44,  446, 

447 
Paine,   Alexander,   257, 

346,  347 


INDEX 


511 


Park,    Roswell    R.,    5,    7, 

29,  92,   93,   285 
Piitersou,  215,  227 
Patterson,   54 
Penhallow,  D.  P.,  45 
Percy,  J.   F.,  308 
Petersen,   192,   290 
Pettit,    A.,    55 
Pick,   L.,   54,   55 
Pilz,    374 
Pinch,    A.    E.    Haywood, 

303 
Pinkuss,     A.,     209,     305, 

330,  343.  447 
Plehn,  55 
Podwyssozki,   116 
I'oincarfi,   297 
Poll,  H..  54 
I'orter,    292 
Potter,  G.  W.,  266 
Pozzi,   384 
Preyss,    320 
Pribam,  192 
Prowazek,   44 
Pryor,    William    R.,    383, 

384 
Pusey,  W.  A.,  285 

Quadrio,  Guiseppe  Maria, 
107 

Raulot-Lapointe,  293,  294 
Reeves,  H.  A.,  266 
Reinelt,  42 
Remak,  Robert,  113 
Repmann,    298 
Ribbert,    Hugo,    114,   115, 

130,  132,  156,  158 
Richardson,    Maurice    H., 

241 
Ricord,  334 
Risley,    Edward    H.,    338, 

339 
Rivi&re,  J.  A.,  308-310 
Robertson,   Alexander,   68 
Rodman,  215,  227,  362 
Rogers,   335 
Rollins,    298 
Rontgen,    291 
Rosenberg,  M.,  209 
Rosenfeld,  Siegfried,  93 
Rosenheim,    227 
Rous,   Peyton,   54 
de  Rouville,  384,  385 
Rowntree,       Cecil,       242, 

292,  293,  369 
Roux,   27,   373,   384 
Rubens-Duval,  303 
Russell,   25,   125 
Russell,     Worthington 

Seton,   312,  325 
Ryall.  Charles,  325 
Ryder,  John  A.,  59 

Salkowski,  192 
SalomoD,    191,    192 


Sanfellce,  329,  332 

Saxl,    191,    192 

Schmidt,    11.   E.,    294 

Schmidt,      Otto,     252-255, 
329,  331,  332 

Schnedel,  333 

Scholl,    329,    332,    334 

Schone,   157 

Schwartze,  318 

Schultz,    290 

Schumacher,  Martin,   107 

Seelye,   H.   H.,  289 

Segond,  312 

Seligmann,  64,  65 

Senn,   Nicholas,  334 

Shaw-Mackenzie,  258,  259 

Shaw,   Mr.,    282 

Sichel,    298 

Simpson,    Sir    J.    Y.,    282 

Sims,   J.    Marion,   283 

Smallwood,    55 

Smith,   Erwin  F.,   41,   42, 
43 

Smith,  William  G.,  41 

Snow,   Herbert,   264 

Spisar,   42 

Spencer,    W.   G.,   51 

Stafford,      Mrs.      Alithea 
Maria,    15 

Stead,    William    T.,    261- 
268 

Stelwagon,  H.  W.,  286 

Stevenson,    86 

Sticker,  Anton,  27,  50,  51 

Stiles,  358,  359,  360,  362 

Stimson,  L.  A.,  336 

Stoloflf,  I.  A.,  203 

Strauss,   330 

Syme,    110,    446,   447 

Sydenham,  13,  14 

Syms,  215 

Sutherland,      David      W., 

66,  67,  68 
Sutton.      See    Bland-Sut- 
ton. 

Tait,  Lawson,  266 

von   Tappelner,   291 

Tatham,   86 

Thayer,   O.  V.,   288,  289 

Theilhaber,    F.,    95 

Thiersch,    108,    111,    112, 

113,   138,  141,  144 
Thomas,  J.  Lynn,  269 
Thompson,   Sir  J.  J.,  303 
Thompson,    W.   B.,   208 
Thorel,  152 
Torek,   Franz,   312 
Tousey,  Sinclair,  291 
Townsend,  42 
Tracy,  Martha,  336 
Travers,  372,  374 
Treves,      Sir      Frederick, 

373,  387 
Tribondeau,  317 
Tricomi,   373 


von  Tubeuf,  41 
Tuffler,    372,   375,   384 
Trunecek,  284 
Tyzzer,  E.  E.,  7,  48,  348, 
349 

Vaillant,   L.,  55,  339 
Vaughan,  J.  W.,  330,  339, 

340 
Vaughan,  V.  C,  336,  339 
Verbrycke,  192 
Vcsalius,    106 
Vidal,    333 
Vlgnat,  Marcel,  284 
Virchow,    108,    111,    113, 

138,  141,  144 
Volkmann,   334 

Waldeyer,    108,    112,   113, 
138,  141,  144,  145 
Walker,  117,  125 
Walshe,    Walter    H.,    106, 

107 
Warden,  A.  A.,  300 
V.    Wassermann.    27,    152, 

162,  177 
von  Wasielewski,  28 
Watson-Cheyne,    352,   359 
Watson,   Sir  Arthur,  15 
Webb,  J.  H.,  258,  259 
Weinberg,   93,   98 
Werner,  Richard,   28,   255 
Wherry,  George,  373,  387 
Whitbread,     Samuel,     13, 

15    282 
Whitehead,   364,  428 
White,    292 

White,  Powell,  119,  131 
Wickham,   297,   298,    299, 

303 
Widmer,    C,    288 
Williams,  298 
Williams,   Idwal  J.,   366 
Williams,  J.  W.,  58 
Williams,    W.    Roger,    45, 

50,  51,  55.  61,  62, 

65,  98 
Winter,   447 
Witzel,    365 
Wlaeff,  329,  332 
Woglom,    W.    H.,    25,    26, 

161,  162,  170 
Wolff,  Jacob,  1 
Wollstein,  Martha,  200 
Wood,   Francis   C,   26 
Woods,   C.    R.,   207 
Woods,  R.  H.,  343 
Woodman,   303 
Woronin,  44 
Wyman,   373 
Wyeth,  John  A.,  329,  333, 

374,  375 

Zenker,  227 
Zeynek,  320 
Zykow,  384 


INDEX  OF  SUBJECTS 


Abderhalden  tests  for 
cancer,  192,  193, 
194 

Abdomen,  cases  showing 
errors  in  diagnosis 
of  cancer  of,  204- 
216 

Abdominal  dropsy,  accom- 
panying abdominal 
cancer.    371 

Abdominal  growths  in 
India,   67 

Abdominal  wall,  cancer 
of  skin  of,  in  na- 
tives of  Kashmir, 
67.  See  also  Site- 
incidence 

Abdominoperineal  opera- 
tion for  cancer  of 
the  rectum,  365, 
366 

Aberrant  thyroid,  mis- 
taken diagnosis  of, 
198,  199 

Abnormal  bud  formation 
in  plants,  41 

Aboriginal  races,  rarity 
of  cancer  in,  63, 
64,  65 

Abscess,    trypsin,    249 
tuberculous,      mistaken 
for  sarcoma,  203 

Acacia,  powdered,  with 
arsenious  acid,  284 

Acanthosis  nigricans,  pre- 
cancerous,   222 

Acetanilid  for  relief  of 
pain  in  cancer, 
427 

Acetic     acid     in     electro- 
cauterization       o  f 
cancer,    306 
in  treatment  of  cancer, 
282,    283,   284 

Acetone   in    treatment   of 
cancer,  388,  427 
following  arterial   liga- 
tion      with       lym- 
phatic block,   393 

Active  immunity  to  can- 
cer.  125 

Active  resistance,  induced 
bv    normal    tissue, 
169,    170,    171 
induced    bv    tumors, 

168.  169 
Induced  by  tumor  and 
normal  tissue, 
comparison  of,  170, 
171 
susceptibility  to,  176, 
177 

Actinotherapy  in  cancer, 
288 

Acute  inflammation,  dif- 
ferentiation o  f , 
from  tumor  for- 
mation,  131 


Acute  trauma  as  cause  of 
cancer,   453 

Adenocarcinoma,  135,  139 

Adenoma,    135,    139 
cured  by  radium,   299 
precancerous,  222 

Adenomyoma,  case  of,  in 
a   mussel,   58 

Adhesions  of  the  stomach 
simulating  cancer, 
205 
treatment  of,  in  ar- 
terial ligation  and 
lymphatic  block, 
393 

Advanced  cancer,  care  of 
cases  of,  33 

Advertisements  of  cancer 
"cures,"  253-255 

"Aesiab  cancer  cure," 
270,   271 

Africa,  rarity  of  cancer 
in,    63 

Age  constitution  in  com- 
pilation of  statis- 
tics, 72,  73 

Age-incidence,   83,   86,   87 
in  animals,   49,  50 
in  calculation  of  death 

rate.    77-79 
in  dogs,  50 

Albumin,  in  urine,  during 
trypsin  treatment, 
250 
with  arsenic,  in  treat- 
ment of  cancer, 
284 

Alcohol,    use  of,   in    can- 
cer, 427 
in    relation    to   cancer, 
81,  128 

Alimentary  system,  pal- 
liative measures 
applied  to,   412 

Alkalies,  use  of,  in  incur- 
able cancer,  427 

Allied  Hospitals,  N.  Y. 
City,   431 

Almshouse  Hospital, 
Blackwell's  Island, 
N.  Y.  City,  432 

Alpha  rays.  297.  298, 
299,  302.  304 

Altitude,  influence  of,  in 
cancer  production, 
61 

Alto-frequent  cytolysis  in 
treatment  of  can- 
cer.   309,    310 

Alt  o-frequent  effleuvia- 
tion  in  treatment 
of  cancer.  309.  310 

Alto-frequent  scintillation 
in  treatment  of 
cancer,   309,  310 

Alum  in  treatment  of  pre- 
cancerous ulcers, 
279 

513 


Aluminum  in  filtration  of 
irritant    rays,    298 

Alveoli.    1.^5,    138 

Ameboid  organisms,  in 
production  of  vege- 
table   tumors,    44 

America,  cancer  research 
in.  5,  6,  7.  Ree 
also  Other  cancer 
research  institu- 
tions, 
lack  of  cancer  statis- 
tics in,   74 

American  Association  for 
Cancer  Research, 
28 

American  cancer  institu- 
tions,  431,   432 

American  method  of  com- 
piling statistics, 
fallacies    in.    73-76 

American  Oncologic  Hos- 
pital, Philadelphia, 
433 

Amphibians,  cancer  In, 
55 

Amvlopsin,  331 
effects  of.  249 

Anaplasia,   116 

Anastomosis   between   as- 
cending    and     de- 
scending   colon, 
413 
between    stomach    and 
small     intestine, 
412 
of  external  carotid  sys- 
tem     with      other 
systems,    378 
possibilities       for,       in 
cases  of  pelvic  can- 
cer,  386 

Ancients,    the    knowledge 
of,  concerning  can- 
cer,   1 
queer  ideas  of,  concern- 
ing treatment,  2 

Anemia,  accompanying 
cancer,    193 

Aneurysm,  ligation  of  ar- 
teries in  treatment 
of,    372 
of  celiac  axis   simulat- 
ing cancer,  205 

Angioma,    139 

among  natives  of  New 

Guinea,  64 
elevated,    precancerous, 

222 
predisposing  to  cancer, 

cases  of,   228 
treatment     of.     with 
mesothorium.    304 
with   thorium   X.  304 

Anilin  workers,   cancer  of 
bladder   in,    127 
papilloma   of  the   blad- 
der in,   81 


514 


INDEX 


Animal     experimentation, 

3'' 
regarding    influonce    or 
liereditv  in  cancer, 
99,    100 
"Animal-gum."      See  Ox- 
gall. 
Animals,  tumors  in,  37 
Anomalies      of      develop- 
ment,   cancer   aris- 
ing  from,   113 
Antacids,    use    of,    in   in- 
curable cancer.  427 
Antimeristem.  252-2.56 
Antlpyrin     for    relief    of 
pain  in  cancer,  427 
Antiseptic   douches.    42R 
ointments,    use    of,    in 

cancer,   427 
solutions,    use    of,    con- 
traindicated         i  n 
cancerous   wounds, 
352 
Antiseptics.         Intestinal, 
use   of,    in    cancer, 
427 
Antitoxic    serum,    blasto- 
mvcetic.   332 
definition  of,   329 
examples  of,   329 
use  of  term,   328 
Antitoxin,     definition    of, 
329 
examples  of,  329 
use   of  term,   328 
Antituman,    331 
Antrum,     cancer     of,     In 

horses,  51 
Anus,  cancer  of,  in  dogs, 

50 
Aperients,    use   of,   in   in- 
curable   cancer, 
426 
Appendicitis,   cancer   mis- 
taken    for,    209, 
210 
with  abscess  formation, 
mistaken    for    can- 
cer, 205,  206 
Approximation   of  wound 
edges  in  cancer  op- 
erations, 353 
Arabia,    rarity   of   cancer 

in,    63 
Arc  light  in  treatment  of 

cancer,  289,  290 
Archaeus,   2 

Argentina,     attitude     to- 
ward   cancer    con- 
ferences,   11 
Aristol,  use  of,  in  cancer, 

428 
"Arphoallne"    in    cauter- 
ization   of    cancer, 
284 
Arsenic,  3,  278,  279,  283. 
284 
hvdro-alcoholic  solution 

"       of.  284 
in  "Arphoaline,"   284 
in  Bougard's  paste,  284 
in     causation     of     can- 
cer,   126 
In  Davis  "cancer  cure, 

274 
in  Manec's  paste,  284 
in  Marsden's  paste,  284 
white,   in   treatment  of 
cancer,    281 
Arsenic  -  cancer    of     the 
skin,   136 


Arsenious  acid,  parenchy- 
matous    injections 
of.  in  cauterizntion 
of    cancer.    2S4 
D'Arsonval's     method     of 
thermopenetration, 
310,    317 
Arterial   lisiation.   .S72-411 
history    of.    372,    373, 
374,  375,  376.  383. 
384,   3S5,   386 
with      ''lymphatic 
block,"      case     of, 
214 
Arteries,  ligation  of.    See 
"Starvation       liga- 
ture." 
Artificially  bred  fish,  can- 
cer in,   55,   56 
Ascites,      chyliform,      fol- 
lowing    carcinoma 
of  the  breast.  341. 
342 
due   to  abdominal   can- 
cer,    drainage     in. 
371 
Ascitic  fluid,  331 

Hodenpyl's.  341-343 
withdrawal    of,    in    ab- 
dominal cancer, 
371 
Aspirin,      use      of.       for 
breaking     morphin 
habit,    425 
for    relief    of    pain    in 
cancer,  427 
Association     Francalse 
pour     I'Etude     du 
Cancer,    27,    28 
Association,     Internation- 
al, for  Cancer  Re- 
search, 9 
Asylums,     cancer.       See 

Cancer  hospitals. 
Atoxyl    in    treatment    of 

cancer,   283 
"Atreptic  immunity,"  452 
Atreptic    theory    of    Ehr- 
lich,    124-126,   177, 
178 
Atrophy  of  epithelial  ele- 
ments   due    to    X- 
ray   exposure,    293 
Atropin    in    treatment   of 

cancer,   427 
Atypical     blastoma.     See 

Crown  gall 
Australia,     cancer    death 

rate  in,   73 
Austria,      cancer      death 

rate  in,    73 
Austrian  Cancer  Commit- 
tee. 25 
Auto-immunization,   168 
Auto-infection,  danger  of, 
in     operating     for 
cancer,  346,  347 
prevention    of,    351 
Auto-intoxication,     avoid- 
ance   of,    in    ther- 
moradiotherapy, 
320 
Autolysates,  in  treatment 
of      cancer,       340, 
341 
Autolvzed     cancer,     330, 

343 
Autopsies,  Importance  of, 
in    compiling    can- 
cer   statistics,    76, 
77 


Autopsies,    rarity    of,    in 

America,   74 
Autoresistance.    174,    175 
Avicenna.   372 
Avidity     of     tumor     cells, 

Ehrlich's  theory  of, 

124.    125 
Autotransplantation       o  f 

cancer,    340 
Autologous  immunization, 

160 
Autologous     inoculations, 

175 
Axillary   glands,   invasion 

of,    in    breast   can- 
cer,  359 

Bacon,    Lord,    13 
Bacillus   prodipiosun    and 
Streptococcus    eri/- 
sipelatosus   toxins, 
329,  333,   335-337 
Bacterial  toxins,  329.  See 
also   Serum, 
use   of   term,    328 
Bacterial    vaccine,    Jacob 

and   Geets',    330 
Bacteriology,  treatment  of 
cancer     based     on, 
332-338 
Bacterium       tumefaeiens, 
crown-gall  due  to, 
42 
Bainbridge's  modification 
o  f         Whitehead's 
shellac,    428 
Barium  sulphate,  in  urine 
of  cancer  patients, 
192 
Barnard    Free    Skin    and 
Cancer       Hospital. 
St.  Louis,  433 
Barnato  bequest,  15 
Belleviie   Hospital,    N.    Y. 

City,  431 
Belgium,      cancer     death 

rate   in,    73 
Benevolent       institutions 
for    care   of    can- 
cer   patients,    432, 
433 
"Benign,"    use    of    term, 

180,  181 
Benign     cystic     epithelio- 
ma,    precancerous, 
222 
Benign  tumors,  131 

among    inhabitants    of 

New  Guinea,   64 
clinical    distinction    be- 
tween      malignant 
tumors    and,    185, 
186 
importance  of  removal 

of,  127 
malignant  degeneration 
of,    222-224 
Benzoin,    compound    tinc- 
ture   of,    in    treat- 
ment    of     cancer, 
428 
Bergen,     Gade     Institute, 

27 
Berlin       Committee,       8, 

Beta  ravs,  297,  298,  299, 

301,   302 
Betton-Massey  method  of 

treating  cancer  by 

ionic  surgery,  323, 

324 


INDEX 


515 


Bichlorid  of  mercury,  use 
of,  with  white  ar- 
senic,   281 

"Big  arm."  See  "Brawny 
arm"  ;  also  Lym- 
phangioplasty. 

Bilateral  retraction  of 
nipple  diagnosed 
as  cancer  of 
breast,    443 

Bile-stones,  cancer  of 
liver  associated 
with,    227 

Bilharziosis.  predisposing 
to  cancer,  127 

Biliary  system,  cancer  of, 
cholecystostomy  in, 
414 
palliative  measures  ap- 
plied   to,    414 

Biological  theories  of 
cancer.  108-117 

Biological  treatment  of 
cancer.  See  Bio- 
therapy. 

Biotherapeutic    agents,  31 

Biotherapy.    327-344 
based    on    bacteriology, 

332-338 
based   on   cytolysins  or 
cytotoxins,     3  3  8- 
343 
classification   of  agents 

for   327,    328 
definition   of   terms   in, 
328,  329 

Bipolar  voltaization  in 
treatment  of  can- 
cer, 322 

Birds,   cancer,  in,  54 

Birds  of  prey,  serum 
from,  in  treatment 
of  cancer,  231 

"Black  art"  and  cancer, 
2 

Bladder,      cancer      of, 
cystostomy  in,  413 
death  rates  from,  78 
following  papillo- 

mata      or      bilhar- 
ziosis,  127 
papilloma  of,   136 
in  anilin  workers,  81 

Blastomvcetic  antitoxic 
serum,   329,   332 

Bleeding.  See  Hemor- 
rhage. 

Blood,    active    resistance 
Induced  by,   169 
changes  in,   in    cancer, 

193 
effect  of  trypsin   injec- 
tions on.   249.   250 
study  of.  in  cancer.  31 

Blood  blister,  sarcoma 
following.    226 

Blood  serum.  330.  331 

Blood  vessels,  spread  of 
cancer  cells 
through,  140,  141 

Body-fluids,  in  treatment 

of  cancer,   841,343 

study  of,  in  cancer,  31 

Bolingbroke,  Lord,  death 
caused  by  cancer 
"cure,"    3 

Bolivia,  attitude  toward 
Cancer  confer- 
ences,  11 

Bones,  secondary  depos- 
its in,  141 


Bonet,    2 

Bonnet,    55 

Booth,     Mrs.     Ballington, 

263 
Booth-Tucker,    262 
Botanical   distribution   of 

cancer,  40-46 
Bougard's    paste    in    cau- 
terization   of    can- 
cer, 283,   284 
Bovines,  cancer  in,  52 
carcinoma  of  caruncula 
of  eye  of,  52 
Brain       tumors,       decom- 
pressive operations 
in,   369,    370.   421 
Branchial  region,  tumors 

of,   in    trout,    57 
"Brand-cancer"  in  cattle, 

48,    52 
"Brawny  arm,"  421,  422 
relief     of,     by     lymph- 
angioplasty,       370, 
371 
Breast,    cancer    of,    443, 
444 
case  of,  68,  216,  423, 

424 
complicated   by  uter- 
ine fibroids,   419 
death-rates    for,    78, 

79,  86 
due  to  irritation,  226 
early    stage    of,    181, 

182 
heredity     and,      100, 

101 
in  animals,    49 
incision    for   removal 

of,  348,  352 
lumpy  condition  in, 
due  to  intestinal 
stasis,  mistaken 
for  cancer,  202, 
203 
mistaken       diagnosis 

of,  443 
operation    for,    based 
upon       permeation 
theory,  362-364 
recurrence  of,   358 
researches      of     Hei- 

denhain  on,  357 
researches    of    Stiles 

on,    358.   359 
thoracocentesis       in, 

371 
Watson  Cheyne's  op- 
eration  for,   359 
X-rav  treatment  for, 
296 
carcinoma  of,  cured  by 
radium,  299 
followed      by      chyli- 
form    ascites,    341. 
342 
inoperable,     sulphate 
of     radium     injec- 
tion for,  302 
cases     showing     errors 
in      diagnosis      of 
cancer  of,   201-203 
fibroadenoma    of,    liga- 
tion   of    mammary 
arteries  in,  373 
malignant   growths   of. 
radium     treatment 
for,  298 
menstrual     lumps     of, 
diagnosed    as    can- 
cer, 445 


Breast,  scirrhus  cancer 
of,  135 

British  Archipelago  in 
Oceanlca,  cancer 
in,   68 

Bromin  in  treatment  of 
cancer,  284 

Brompton  Cancer  Hos- 
pital, research  de- 
partment,  25 

"Broussins,"   45 

Buccal       mucous       mem- 
brane,    cancer    of, 
In  India,  67 
radium  treatment  of, 
298 

Buffalo,  University  of. 
5,  6 

Burn,  epithelioma  in  scar 
from,  229 

Burrs,    48 

Buttock,  sarcoma  of.  liga- 
tion of  internal 
iliac  artery  in.  373 

Byrne  method  of  electro- 
cauterization  of 
uterine  cancer, 

306-308,   388 

Cachexia,     a     late     mani- 
festation,   184 
causes  of,  422 
effect  of  amylapsin  on, 

249 
in     incurable      cancer, 

426 
reduced     by     Coca-Gil- 
man  emulsion,  339 
relief    of,     by    arterial 
ligation,  388 
Cage  infection   with   can- 
cer,   152 
Calculi,    cancer    of    liver, 
gall-bladder,     bile- 
ducts,      and      pan- 
creas, due  to,  227 
Calomel,      use     of,     with 
white  arsenic,   281 
Campaign     of     education 
concerning    cancer, 
31,  438-451 
applied  to   the   medical 
profession,        440- 
444,    445 
applied    to    the    public, 

445-447 
cases   illustrating   need 

for,    442-445. 
how    best    to    conduct, 

447-451 
publicitv    methods    in, 
447,  448 
Cancer  a  deux,  93 
"Cancer   bodies,"    41 
"Cancer  bush,"  3 
Cancer      cells,      arrange- 
ment of,   134,    135 
Cancer  census,  8,  9 
Cancer    Charity     of    the 
Middlesex       H  o  s- 
pital,   London,   431 
Cancer      Commission      of 
Harvard       Univer- 
sity. 6 
"Cancer    Curers,"    Cardi- 
gan  (Wales),   268- 
270 
"Cancer    cures"  : 
Aesiab,  270.  271 
Cardigan.  268-270 
Davis,    271-275 


516 


INDEX 


"Cancer    cures" : 
Mattei      "electricities," 
261-268 
Cancer     epidemics,      118, 
123 
among  mice,  152 
among  trout,  55,  57 
Cancer    Hospital,    Bromp- 

ton,  London,  431 
Cancer  Hospital,  London, 
Research       Depart- 
ment, 29 
Cancer  hospitals,  32-35 
"Cancer  houses,"   03.   105 
Cancer   Institute,    Heidel- 
berg.  8,   11,   25,   28 
Cancer   institutions,    429- 
437 
in  America,  431,  432 
benevolent,    432,    433 
in  Europe,  429-431 
private.  432 
"quack,"  433.  434 
Cancer      Laboratory      of 
New     York     State 
Board  of  Health,  6 
Cancer    research,    bearing 
of  immunity   reac- 
tions and  propaga- 
tion on  the  nature 
of  cancer.   161-177 
in   Germany,  7,  8 
practical      results      of, 

144-154 
theoretical    results    of, 
154-160 
"Cancerous  virus,"  106 
Cancroidin,  252-256 
Cancroids    of    face    cured 

by  radium,  299 
Canquoin's  paste  in  cau- 
terization of  can- 
cer, 283 
"Cape  of  Good  Hope  Re- 
port of  Select  Com- 
mittee on  Mrs.  Van 
Niekerk's  Peti- 

tion,"   270,    271 
Capillary  angioma  predis- 
posing   to    cancer, 
228 
Capillary   oozing,    preven- 
tion   of,    in    opera- 
tion    for      cancer, 
351 
Carbolic    acid    in    electro- 
cauterization        of 
cancer,  306 
injection    of,    in    treat- 
ment    of     cancer, 
284 
Carcinoma,  132,   139 
development      of      sar- 
coma    from,     164, 
165 
differentiated  from  sar- 
coma, 112 
due  to  X-ray  exposure, 

293 
examination     of     urine 
in      diagnosis      of, 
191,  192 
in   dogs,   50 
in    India,    67 
in  X-ray  workers,  292 
inoperable,      relief     of, 

by  radium,  300 
of      breast,      case      of, 
followed   by   chyli- 
form  ascites,  cured 
by  radium,   299 


Carcinoma,   of   caruncula 
of  the  eye  in  bov- 
ines,   52 
of  face  and  mouth,  liga- 
tion and  exsection 
of  external  carotid 
artery  in,  380 
of      superior      maxilla, 
cured    by    radium, 
299 
of  tongue,  case  of,  200, 
201 
radium         treatment 
for.   299 
of  uterus,  mesothorlum 
treatment  for,  305 
radium         treatment 
for,    299,    302,    305 
squamous-celled,    disap- 
pearance of,  under 
X-ray      treatment, 
324 
transplantation  of,  150, 

151 
treatment   of,    by    sun- 
light, 288 
with        mesothorium, 

304 
with  thorium  X,  304 
X-ray,   295 
Carcinoma  -  sarcomatodes, 

140 
Cardigan      "caucer      cur- 

ers."   208-270 
Carotid     artery,     ligation 
and     resection     of, 
in     malignant     tu- 
mors of  head,  374- 
382 
cases  of,  420 
first  case  of,  372,  373 
indications  for.  379 
objections   to,  380,   381 
summary  of  results  of, 

381,  382 
technic    of,    376,    377, 
378,    379 
Cartilaginous  tumors, 

growth  of.   131 
Caruncula,    carcinoma   of, 

in  bovines,  52 
Castration,      development 
of    cancer    follow- 
ing, 52 
Casts     in     urine     during 
trypsin    treatment, 
250 
Cat,   cancer  in,   51 
Cataphoresis      in      treat- 
ment    of     cancer, 
323,  324 
Catgut    for    ligatures    in 
cancer      operation, 
351 
Catheterization  of  ureters 
preliminary   to   op- 
eration for  uterine 
cancer,   353 
Cattle,   cancer  in,  52 
Caustic    potash   in   treat- 
ment    of     cancer, 
283 
Caustics  as  used  by  der- 
matologists,     285, 
286 
in  treatment  of  cancer, 
277,  280,  281,  282- 
286 
in     treatment    of    epi- 
thelioma   of    skin, 
285 


Caustics,     in     treatment 
of   squamous  -  cell 
e  pithelioma, 
286 
list     of     "useful,"     for 
treatment    of   can- 
cer,  283 
of  vegetable  origin,  285 
use    of,    facilitated    by 
arterial       ligation, 
388 

Cauterization,    by    Byrne 
method,   306-308 
facilitated     by     arte- 
rial ligation,  388 
by     hypodermic     injec- 
tion, 282 
in   connection  with  op- 
eration for  ulcerat- 
ing cancer,   350 
in  treatment  of  cancer, 
methods     of,     281- 
283 

Cell  division  in  cancer, 
116,   117 

Cell  proliferation  in 
cancer,  132,  140, 
141 
stimulation  of,  due  to 
small  doses  of  X- 
ray,  294 
in  tumors,  119,  120 

Cellular  infiltration  in 
tissue  adjacent  to 
early  carcinoma, 
115 

Celsus,    1,   106.   372 

Central  America,  cancer 
in,  60 

Cerebral  tumor,  decom- 
pression  opera- 
tions in,  369,  370, 
421 
thermoradiotherapy  in, 
316 

Cervical  tears,  associated 
with  cancer  of  the 
uterus,   226.   227 

Cervix,  cancer  of,  curet- 
tage and  arterial 
ligation  in,   387 

Cervix,  uterine,  inopera- 
ble carcinoma  of, 
radium  salts 
treatment  for,  302 

Chalk,  influence  of,  in 
cancer  causation, 
128 

CharitS.  Berlin,  pavilion 
for  cancer,  8,  26, 
29,  431 

Cheek,  cancer  of,  case  of, 
68 
in  India,  67 
cured  by  radium  radia- 
tion. 300 

Cheiloplasty  following 
operation  for  can- 
cer of  the  lips.  369 

Chemical  irritants,  influ- 
ence of,  in  produc- 
tion and  develop- 
ment of  cancer,  48 

Cheyne's  operation  for 
breast  cancer,  359 

Chian  turpentine,  257, 
258 

Chimney-sweeps,      cancer 
in.   81 
cancer    of    scrotum    in, 
126 


INDEX 


517 


China,     attitude     toward 
cancer  conferences, 
11 
cancer  in,  63,   72 

Chlorid  of  gold  in  treat- 
ment of  cancer, 
285 

Chlorid  of  zinc  in  treat- 
ment of  cancer, 
278,   279.   281,  282 

Choked  disc  in  brain 
tumors,  relief  of, 
by  decompression 
operation,  369 

Cholocystenterostomy,414 

Cholecystostomy,   414 

Cholcsterin  in  soap  solu- 
tion and  oxgall, 
258,  259 

Cholln  in  treatment  of 
cancer,  286 

Chondroma,   139 

Christie  Hospital,  Man- 
chester, cancer  pa- 
vilion and  house, 
431 

Chromic  acid  in  treat- 
ment of  cancer, 
283,  284 

Chronic  gastritis,  predis- 
posing    to     cancer 
of     the      stomach, 
227 
simulating  cancer,    205 

Chronic  inflammations, 
differentiation  of, 
from  malignant 
growths,  131 
leading  to  cancer, 
sources  of,  225, 
227,  228 

Chronic  intestinal  stasis 
diagnosed  as  can- 
cer, 443.  444 

Chronic       iritation,        as 
cause     of     cancer, 
286,  288.  451,  452, 
453 
influence  of,  in  cancer 
causation,    67,    81, 
104,  111,  112,  113, 
123,  126.  127,  128, 
153,  154 
leading       to       cancer, 
sources     of.      225- 
228 
prevention  of,  after  op- 
eration, 348 

Chronic  ulcer,  predispos- 
ing to  cancer,    127 

Chuna's  powder  in  treat- 
ment of  cancer  of 
face,  282 

Chyliform  ascites,  follow- 
ing carcinoma, 
341,  342 

Cicatricial  contractions, 
causing  pressure 
upon  the  ureter, 
394 

Cinnabar  with  arsenic, 
284 

Circumcision,  relation  of, 
to  cancer  of  penis, 
67 

Cirrhosis  of  liver,  simu- 
lating cancer,  205 

City  Hospital,  Black- 
well's  Island,  New 
York  City,  431, 
432 


Clamps,  danger  from  use 
of,  in  cancer  op- 
erations, 351 

Classification  of  tumors, 
137-140 

"Clay  pipe"  cancer,  68 

Cleanliness,  relation  of, 
to  cancer,  92 

"Clearing-house"  for  can- 
cer, 31 

Climate,  influence  of,  in 
cancer  production, 
60 

Clinical  and  experimental 
work,         comple- 
ments, 32 
possibilities  of,  32 
utility  of  combining  or 
separating,  32 

Clinical  course  of  can- 
cer, 180-184,  185, 
186,    187 

Clinical  diagnosis  of  can- 
cer, 188-190 
supplemented  by  micro- 
scopic      diagnosis, 
194 

Clinical  Investigation,   36 

"Club-root,"  40 

Coagulation  of  tissues  in 
destruction  of  tu- 
mors, 320 

Coal,  cancer  in  laborers 
with,   80,   81 

Coca-Gilman  emulsion, 
330,  338,  339 

Cohnheim's  theory  of 
cancer     causation, 

27,  113.  114 
Colectomy,   413 

Coley's  fluid,  329,  333- 
337 

"Collective  investiga- 

tion," 11,  12 

Collis  P.  Huntington 
Memorial  Hospi- 
tal,  433 

Colloidal  copper  in  treat- 
ment of  cancer, 
286 

Cologne,  cancer  labora- 
tory,  25 

Colon,  cancer  of,  colosto- 
my in,   412 

Colostomy,   412,   413,  421 

Columbia  University, 

Crocker  Cancer 
Fund,  26 

Commission.  See  Cancer 
Commission. 

Committee,  Austrian,  25 

Committee,  German,  for 
Cancer  Research, 
7,  8,  9.  28,  29 

Common  iliac  artery, 
ligation  of,  391 

Comparative  study  of 
cancer  and  other 
skin  lesions.   31 

Comparison  of  methods 
of       investigation, 

28,  32,  33 
Compilation  of  statistics. 

See  Statistics. 
Complications    of    cancer, 

421 
leading      to      diagnosis 

of  irremovable 

growth,  419 
Concomitant       resistance, 

174,  175 


Conference,  Interna- 
tional,  8,  9,  28 

Congenital  anomalies,  de- 
velopment of  can- 
cer on,  123 

Congenital  theory  of  can- 
cer. See  Embry- 
onic theory. 

Connective      tissue,       ar- 
rangement   of,     in 
cancer,  135 
effect     of     X-rays     on, 

293 
nature  of,  in  classifica- 
tion     of      tumors, 
140 
relation     of     epithelial 

tissue  and.  138 
rOle      of,      in      cancer 
causation,  111, 

112,  113.  115 

Constancy  of  histological 
structures,         162, 
163 
of    power     to    develop 

sarcoma,  164 
of  tumor  cells,  162 

Constipation,    in    incura- 
ble cancer,  426 
ulceration         following 
persistent,  221 

Constitutional  theory  of 
cancer,  141,  142, 
145,  183 

Contact,  relation  of,  to 
cancer,  94 

Contagiousness  of  can- 
cer,  34 

Continuous  growth,  ac- 
quisition of  pow- 
ers of,  175.  176 

Continuous  tumors  in 
plants,    45 

Contraindications  to  sur- 
gical treatment, 
347 

Coolidge  X-ray  tube,  294, 
324 

Cooling  of  tissue  surface 
in  thermoradio- 
therapy, 319,  320 

Corrected  death-rates,  72, 
73 
comparison     of     crude 
rates  with,  90 

Country,  frequency  of 
cancer  in,  90 

Cremation,  advocated  in 
deaths  from  can- 
cer,  92 

Criticisms  of  value  of 
propagation,  154- 
160 

Crocker,  George,  Special 
Research  Fund.  26 

Croft,  Caroline  Brewer, 
6 

Crowngall  in  plants,  re- 
semblance of,  to 
cancer,  41-43,  44, 
45.  46 

Crow's  feet.  See  Plun- 
ket's  Paste. 

Crude  death  rates,  72,  73 
comparison       of       cor- 
rected  rates    with, 
90 

Crystallization   theory   of 

cancer,   111,  138 
"Cures,"    1,   3.      See   also 
"Cancer   cures." 


518 


INDEX 


Cnrettago,  facilitated  hy 
arterial  ligation, 
38S,  390 
following  arterial  liga- 
tion and  lym- 
phatic block,  393 
in     cancer     of     cervix, 

387 
in     treatment    of    can- 
cer, 428 

Cutaneous  cancer.  See 
Skin,  cancer  of. 

Cyst,  ovarian,  accompa- 
nied by  cancer, 
case  -of,  212 

Cystostomy,    413,    421 

Cytolysins,  treatment  of 
cancer  based  on, 
338-343 

Cytolytic  reactions  in 
cancer  diagnosis, 
193,   194 

Cytolytic  scrum  of  von 
Leyden  and  Blu- 
menthal,   328 

Cytotoxins,  treatment  of 
cancer  based  on, 
338-343 

Czorny"s  Samariterhaus, 
8,  11,  25,  28,  29 

Dagga  smoker,  3 
Dahlen    Institute    for  Ex- 
perimental Re- 
search,   26 
Daniels   Ethnological   Ex- 
pedition,  64 
Pa  Vinci,   106 
Davis    cancer    cure    (Mel- 
bourne, Australia), 
271-275 
Dawbarn  method  of  liga- 
tion   and    excision 
of  external  carotid 
artery     in     malig- 
nant     tumors      of 
mouth     and     face, 
374-382 
Death-rate       in       cancer, 
compared          with 
death     rate     from 
infectious  diseases, 
93 
conditions      of      living 

and,  92,  93 
corrected,    72,    73 
crude,  72,  73 
factors    to    be    consid- 
ered    in     calculat- 
ing, 77-79 
for    parts    of   the   body 
for     various     age- 
groups      of      both 
sexes,   78 
in     England     and     Ire- 
land,  90,    91 
in  various  age  periods, 
from  1861  to  1870 
and  in  1896,  83 
in  various  countries  of 
the  world,  73 
Decompressive   or    decom- 
pression opera- 
tions for  cancer  of 
the      brain,       369, 
370,   421 
Definition  of  cancer,  130- 

132 
de  Keating-Hart.    See  Ful- 
guration  ;f7Z.so  Ther- 
moradiotherapy. 


Dentist,    part   of,    in    pro- 
phylaxis of  cancer. 
226 
Deodorizers,     use    of,     in 
rooms     of     cancer 
patients,   427 
Dermatitis,       destructive, 
due  to  X-rays,  293 
in  rats.  292,  293 
predisposing  to  cancer, 
127,   222 
Dermatological        depart- 
ment.    New     York 
Skin     and     Cancer 
Hospital,    31 
Dermatological      use      of 

caustics,  285,  286 
Descartes,    106 
Descent    of    cancer    from 

normal   tissue,   33 
Destruction  of  tissue  pro- 
duced  by   high-fre- 
quency        current, 
322 
by    large    doses    of    X- 
ray,   294 
"Destructive  fulgura- 

tion,"   310,  323 
Diagnosis  of  cancer,   188- 
194 
accuracy  in, 

importance    of,     437, 

440 
death-rates      affected 
b.v,   86,    89 
clinical,   188-190 
errors    in,    cases    illus- 
trating,   443,    444, 
445 
failure    to   operate   due 
to,   419 
statistics      of,      195, 
196 
microscopic,    190,    191 
outlook    for,   in   future, 

453 
possible  errors  in,  195- 
219 
abdomen,        204-214, 

215,    216 
breast.   201-203 
head,    196-199 
pelvic     organs,     216- 

219 
tongue,  199-201 
sero-,    191-194 
surgery  and,   353,  354 
Diathermy    in    treatment 
of  cancer,  320,  321 
Diet,    goiter    in    fish    due 
to,   58 
in   prophylaxis   of   can- 
cer, 221 
influence  of  climate  on, 

60 
Influence  of.   In    cancer 
production,  61,  62, 
64,   69,   82,   128 
in     cancer     distribu- 
tion, 48 
in  treatment  of  cancer, 
388,   422,  426,   427 
Differentiation    in    study 

of  cancer,  453 
Digestives,  in  treatment 
of  cancer,  422, 
426 
Discharge,  in  pelvic  can- 
cer, relief  of,  by 
arterial  ligation, 
390 


"Direct  method"  of 
studying  cancer, 
38 

Disinfection,  advocated 
in  cancer,  92 

Dissemination  of  tumor, 
185 

Distribution     of     cancer, 
general,  37-69 
botanical,  40-46 
geographical    and    eth- 
nological, 60-69 
zoological,   47-59 

Dog  fennel.  See  Plun- 
ket's  Paste,  3 

Domestic  animals,  cancer 
in,  47 

Domesticated  fowls,  neo- 
plasms in,  54 

Dogs,  cancer  in,   50,  51 

Donkey,  blood  serum,  331 

Dosage,  general  rule  for, 
in  fulguration,  315 

Douches,   antiseptic.  428 

Doyen    apparatus    for    bi- 
polar  voltaization, 
322 
for     electrocoagulation, 
321 

Doyen's  serum,  256,  257, 
329.   332 

Doyen's  vaccine,  330,  332 

"Dr.  Fell  Treatment"  of 
cancer  with  zinc 
chlorid,   283 

Drainage  of  the  kidney, 
413 

Drainage  tubes,  in  can- 
cer operations, 
351,  363 

Dropsy,  abdominal,  ac- 
companying ab- 
dominal cancer, 
371 

Dundee  cancer  labora- 
tory, 25 

Duration  of  fulguration, 
315 

Duration  of  life  in  can- 
cer,  184,  185 

Early  stages  of  cancer, 
181,   182 

Education,    campaign    of, 
438-451 
of    medical    profession, 

440-445 
of  nurses  and  Internes 
in    care  of   cancer 
patients,  31 
of  the  public,  445,  447 

Egypt,  cancer  In,  63,  72 

Ehrlich's  atreptic  theory, 
124-126 

Ehrlich's  Institute,  27, 
29 

Electrical  technic  of  ful- 
guration, 314,  315, 
316 

"Electricities,"  Mattel, 
for  treatment  of 
cancer,  261-266, 
267,  268 

Electricity  in  treatment 
of  cancer,  287, 
289-296 

Electrocauterization        in 
destruction  of  can- 
cer,  310,    388 
In  treatment  of  uterine 
cancer,  306-308 


INDEX 


519 


Electrocautery,  in  treat- 
ment of  cancer, 
306-308 

Electrocoagulation  in 

treatment    of    can- 
cer, 321,  322,  325, 
326 
Doyen     apparatus    for, 
321 

'Electrohomeopathic  sys- 
tem" of  treating 
cancer,  261-268 

Electrotherapy  in  can- 
cer,  287 

Elevated  angiomata,  pre- 
cancerous, 222 

Elevated  angioma,  predis- 
posing to  cancer, 
cases  of,  228 

Emanation,  radium,  297 

Embolic  theory  of  cancer 
dissemination,  358, 
359,  360 

Embolus,  death  from,  in 
cancer,  186 

Embryonic  rests,  theory 
of  cancer  as  due 
to,   113 

Embryonic  theory  of  can- 
cer, bearing  of  ex- 
perimental investi- 
gations on,  128, 
124 

Embryonic  skin,  active 
resistance  induced 
by,  169,  170 

Emmerich  and  Scholl's 
serum,   329,   332 

"Emotional  surgery,"  416 

Emulsion,       Coea-Gilman, 
330,  338,  339 
definition  of,  330,  331 
Fichera,  330 
in  treatment  of  cancer, 

338-341 
of        fetal        products, 

Fichera,  340,  341 
use  of  term,   328 

Emunctory  organs,  care 
of,  in  incurable 
cancer,  425,  426 

Encephaloid  cancer, 
among  natives  of 
New  Guinea,  64 

Encyclopedia  of  Kolle 
and  Wassermann, 
162 

Endemics,  cancer,  152 

Endogenous  origin  of 
cancer,  145,  178 

Endothelioma,   139 

treatment       of,       with 
mesothorium,  304 
with       thorium       X, 
304 

"End-result"  cases,  31 

Enemata,  use  of,  in  in- 
curable cancer, 
426 

England,  attitude  toward 
cancer       confer- 
ences, 9,  10,  11 
cancer     death-rate     in, 
73 
compared  to  Ireland, 
90,  91 
cancer  research  in,  11- 

25 
See  also  Other   Cancer 
Research      Institu- 
tions. 


England,  increase  of  can- 
cer in,   82 
mortnlity    statistics   in, 
102 

England  and   Wales,   age- 
incidence  of  cancer 
in.   88,   89 
ago    of    population    of, 
88 

English  campaign  against 
cancer,  439,  440 

English  cancer  Institu- 
tions,   430 

Enlarged  glands  around 
bifurcation  of 

common    iliac,    re- 
moval of,    389 

Entero-enterostomy,    421 

Environment,     etiological 
influence     of,     37, 
127,    128 
in   prophylaxis   of  can- 
cer, 221,  222 

Environmental  changes, 
influence  of,  on 
cancer  distribu- 
tion, 47 
in  production  of  can- 
cer, 6.3-66 

Enzyme  body,  presence 
of,  in  urine,  in 
cancer  cases,   250 

Enzyme  treatment,  30, 
242-251 

Eosin  in  treatment  of 
cutaneous  cancer, 
291 

Eosinophilla,  trypsin 
treatment  and, 

250 

Epidemics,     cancer,     118, 
123 
among  mice,  152 
among  trout,  55.  57 

Epithelial  elements,  ef- 
fect of  X-rays  on, 
293 

Epithelial  tissue,  relation 
of  connective  tis- 
sue and,  138 

Epithelioma  among  na- 
tives of  New 
Guinea,  64 
at  base  of  horn  in  cat- 
tle, 48,  52 
benign  cystic,  precan- 
cerous,   222 

Epithelioma,   case  of.   de- 
V  e  1  o  p  i  n  g     from 
small   nodule.   231- 
233,   235 
effect  of  radium   treat- 
ment on,   298,   303 
following   scar    from    a 
burn,   case  of,   229 
light-therapy   for,   290 
of    frontal    region,    fol- 
lowing  small  nod- 
ule   in     the     skin, 
229,   230 
of  face,   high-frequency 
currents    in    treat- 
ment of.  309 
of     lip,     case     of.     in 

Tarawa,  68 
of  lip  and  glands  of 
neck,  case  of,  191 
of  orbit  and  adjacent 
structures,  follow- 
ing small  ulcer, 
230 


Epithelioma  of  scalp.  In- 
volving external 
table  of  skull  and 
dlploe,  mlstakt^n 
for  syphilis,  197, 
198 
of    skin    of    abdominal 

wall,  67 
of    skin,     cauterization 
as    treatment    for, 
285 
X-ray  treatment  for, 
285 
of  tip   of   tongue,    case 

of,    200 
of        tongue,        radium 

treatment  of,  302 
of  vulva,  radium  treat- 
ment of,  302 
radium-sensitiveness  of, 

318 
squamous-cell,     use     of 

caustics  for,   286 
sunlight    treatment    of, 

288 
superficial,  sunlight 

treatment  for,  289 
X-ray  treatment  of.  295 
Epithelium,     role    of,     in 
cancer      causation. 
Ill,  112,  113,  115, 
135 
Eppendorfer  Hospital, 

Hamburg,       cancer 
patients  at,   431 
Epulis,  malignant,  due  to 
faulty        dental 
work,  226 
Errors   in  diagnosis,   pos- 
sible, 195-219.    See 
also  Diagnosis. 
Erysipelas,   as  a  curative 
agent     in     cancer, 
333-335 
effect     of,     on     concur- 
rent disease,  333 
Erysipelas        toxins        in 
treatment    of    can- 
cer, 333-337 
Escharotics  in   treatment 
of  cancer,  277-286. 
See   also   Caustics. 
Esculin    with    X-rays    or 
radium     in     treat- 
ment    of     cancer, 
291 
Esophagostomy,   412,   421 
Esophagus,       cancer      of, 
gastrostomy         in, 
412 
obstruction     of,     relief 
of,   421 
Esquimos,    cancer  among, 

60,  63 
Ethnological    distribution 
of   cancer,    38,    39, 
60-69 
Etiology,   Adami's  theory 
of,  116 
Benecke's      theory      of, 

116 
biological    theories    of, 

108-117 
Cohnheim's    theory    of, 

113,  114 
early   theories  of,    106, 

107 
Ehrlich's    atreptic    the- 
ory, 124-126 
"embrvonic    rest"    the- 
ory of,  113 


520 


INDEX 


Etiology,  failure  of  oxper- 
iniental    study     to 
establish.     144-14r> 
Farmer,      Moore,      and 
Walker's        theory 
of,  117 
von    Ilansemann's    the- 
ory of,  11<> 
Hauser's       theory       of, 

115,   11« 
ideas    of    the    Ancients 

concerning,    1 
Marchand's    theory    of, 

IIG 
parasitic     theories     of, 

117-121 
predisposing         causes, 

122-129 
relation     of     statistics 

to,  91-104 
Kibberfs       theory      of, 

114,   115 
Thiersch's     theory     of, 

111 
Virchow's     theory     of, 

111, 
Waldever's    theory     of, 
li2,  113 
Euphorbia     in    treatment 
of  cancer,  279,  2.S5 
European   cancer  institu- 
tions, 429-431 
Evans,   Daniel  and  John. 
See    "Cancer    Cur- 
ers."' 
Experimental     and     clin- 
ical  work,   comple- 
ments, 32 
possibilities  of,   32 
Experimental       investiga- 
tions,   bearing    of. 
upon     theories     of 
cancer      causation, 
122-124 
failure  of,   to  establish 

etiology,  144-14G 
"limitless"     growth    of 

cancer,   149,   150 
individuality  of  cancer 
established  by, 

147,  148 
Experimental     production 
of  cancer  with  ra- 
dium, 303 
with  X-rays.  293 
Exploratory     laparotomy, 
210,  211,  212,  215, 
216,  354 
importance  of,  204 
Exploratory        operation, 

190 
Exsanguination,     prelimi- 
narv     to     sunlight 
therapy,  289,  290 
Bisection  of  the  external 
carotid    artery    in 
treatment    of    ma- 
lignant   tumors    of 
the    mouth    and 
face,  376-382 
Extension    of    malignant 
growths,      checked 
bv     arterial     liga- 
tion,   387 
External    carotid    artery. 
See      Carotid      ar- 
tery. 
Extracts,     definition     of, 
330,    331 
in    treatment    of    can- 
cer, 338-341 


Extracts,     use    of    term, 

328 
Extramural      spread      of 

cancer    of    rectum, 

366 

Face,  cancer  of,  Ghana's 
powder  for,  282 
death-rates    for,     78, 

79 
fluorescent     stimula- 
tion   in    treatment 
of,   291 
cancroids   of,   cured   by 

radium,   299 
epithelioma     of,     high- 
frequency   currents 
in     treatment    of, 
309 
malignant    tumors    of, 
ligation  and  exseo- 
tion     of     external 
carotid    artery    in, 
374-382 
Facial    paralysis,    danger 
of,    urged    against 
carotid       excision, 
380 
Fallopius,    106 
Falsification      of      death 
returns,     95,     101, 
102 
Family     histories,     show- 
ing     influence      of 
heredity  in  cancer, 
100,  101 
Fascial   planes,   operation 
in    line   with,    347, 
348 
Fell   treatment,    2S2.    283 
Ferments,       attempt       to 
demonstrate,         in 
serum     of     cancer 
patients,  194 
Fetal     products,     Fichera 
emulsion    of,    340, 
341 
Fetor,    relief  of,   427 
by      artorii'l      ligation, 
388,    390 
Fibro-adenoma,  139 

of   the   breast,    ligation 
of     mammary     ar- 
teries in,  373 
mistaken  for  cancer, 
202 
Fibrocheloid      formations 
among    natives    of 
New  Guiqea.  64 
Fibroid    tumor,    case    of, 
in  a  goose,  54 
uterine,        complicating 
cancer        of        the 
breast,    419 
of  uterus,  mistaken  for 
cancer.   216 
Fibrolipoma,    139 

of  breast,  mistaken  for 
cancer,  202 
Fibroma,   139 

among   natives  of   New 

Guinea,   64 
case    of,    in    a    python, 

55 
development      of      sar- 
coma from.  223 
Fibrosarcoma,  139 
Fichera  emulsion,  330 
of  fetal   products.   340, 
341 
"Filth  diseases,"   92,   104 


Filtration       of       irritant 

rays.  298 
"Flnger-and-toe"    disease, 

in  plants,  40 
Finsen   concentrating   ap- 
paratus    for     sun- 
light therapy,   289 
Finsen     lamp     for     light- 
therapy,   289 
Finsen-Reyn  arc  lamp  for 

light-therapy,  290 
Finsen's    Light    Institute 
at         Copenhagen, 
289 
First    institution     devot- 
ed   exclusively    to 
study  of  cancer,  5, 
6 
Fish,  cancer  in,  55-58 

tumors  in,    55-58 
Fissures    of    cervix,    pre- 
disposing   to    can- 
cer,   127 
of   nipple,    predisposing 
to    cancer,    226 
"Fluids,"     use    of    term, 

328 
Fluorescent       stimulation 
in      treatment      of 
cancer,  291 
Fluorescln     with     X-rays 
or  radium  in  treat- 
ment    of     cancer, 
291 
Food     inspection,     impor- 
tance of,  59 
Fordham    Home    for    In- 
curables,      N.       Y. 
Cit.v,   432 
Formalin  in  treatment  of 
cancer,     279,     283. 
284 
Formic  acid  in  treatment 
of      cancer,       279, 
283,   284 
Fowl,  neoplasms  in,  54 
France,    attitude    toward 
cancer       confer- 
ences, 9,  11,  27 
Frogs,    green,    as    cancer 
"cure,"  2 
tumors    in,    55 
Frost,     vegetable    tumors 

due  to,  41 
Fruits,  use  of,  in  relation 
to  cancer,  82 
attempts  to  supplant 
surgery   with,    28 
Fulguration,   de   Keatlng- 
H  a  r  t,       310-316, 
325,  326,  416 
apparatus  for,  312 
causes  of  failure   in, 

316 
contraindication  for, 
due  to  location  of 
tumor,  316 
Czerny's     attempts     to 
supplant      surgery 
with,    28 
"destructive,"  310,  323 
not    "desiccation,"    323 
duration  of,  316 
effect  of,  on  color  of 

tissues,   315 
electrical  technic  of, 

314-316 
instrumentation    and 
technic  of.  312-314 
surgical    technic    of, 
314 


INDEX 


521 


Fulguration,      thporetical 
basis  of,  310,  311, 
316 
with      thermoradio- 
therapy, 317 

Fungating     masses,     care 
of,   427,    428 

Gade  Institute,  Bergen,  27 
Galen,    1,    106,    372 
Gall    bladder,    cancer    of, 
death      rates     for, 
78,    86 
Gall    stones,    cancer    mis- 
taken for,  210,  211 
predisposing  to  cancer, 

127 
simulating   cancer,   205 
Galls,    41-45 

Galvanocautery   in    treat- 
ment    of      cancer, 
427 
Gamma    rays,    297,    301, 

324 
Gametoid   theory   of  can- 
cer,   117 
Gangrene,     arterial     liga- 
tion and,  380,  390 
Gastralgia,    nervous,    sim- 
ulating cancer,  205 
Gastric  cancer,  predispos- 
ing causes  of,   227 
rarity   of,   in   dogs,   51. 
See  also  Stomach,  can- 
cer of. 
Gastric    ulcer,    cancer    of 
stomach  following, 
227 
Gastritis,   chronic,  predis- 
posing    to     cancer 
of     the      stomach, 
227 
simulating   cancer,    205 
Gastroduodenostomy,    412 
Gastro-enterostomy,    412 
Gastrojejunostomy,    412 
Gastrostomj%    412,    421 
Gauze,    use    of,    contrain- 
dicated     in     dress- 
ing cancer  wounds, 
353 
General     distribution     of 

cancer,    30-69 
General  Memorial   Hospi- 
tal,    N.     Y.     City, 
431,    432 
Geographical    and    ethno- 
logical distribution 
of  cancer,    60-69 
in    Gilbert    Islands,    68 
in   Iceland,    68,   69 
in  India,  66-68 
influence      of      climate, 
soil,     diet,     and 
habits    of    life    on, 
60-62 
influence     of     environ- 
mental changes  on, 
63-66 
racial     immunity     and, 
62,    63 
Germany,  attitude  toward 
cancer  conferences, 
8,    9,    10,     11 
cancer    research    in,    7- 
11.  See  also  Other 
cancer  research  in- 
stitutions. 
"Germinal    rest,"    theory 
of     cancer     causa- 
tion,  27 


German  Cancer  Commit- 
tee, 7,  9,  28,  29 

Gilbert  Islands,  cancer 
in,    68 

Gland  structure,  repro- 
duction of,  in 
new  growths,  134, 
135 

Glands  of  neck,  epi- 
thelioma of,  case 
of,    191 

Glands,  removal  of,  in 
connection  with 
arterial  ligation 
with  lymphatic 
block,   392,   394 

Glioma,    132,    139 

Gliosarcoma,    132 

Glossitis,  precancerous, 
127 

Glycerin  in  electrocau- 
terization  of  can- 
cer, 306 

Glycogen  formation  iu 
transplanted  tu- 
mors,   163 

Goats,   cancer  in,   52 

Goiter,  development  of 
cancer  on,  in  fish, 
57,  58 

Goose,    neoplasms    in,    54 

Grafting.  See  Transplan- 
tation. 

Grafting,  skin,  following 
operation  for  can- 
cer,   352,    368 

Granulation,  following 
cancer  operations, 
353 

Granuloma,    131 

Gratwiek  Research  Lab- 
oratory,  6 

Greece,  attitude  toward 
cancer  conferences, 
11 

Green  frogs,  a  cancer 
"cure,"    2 

Gross,  Samuel  D.,  prize 
essay,  375 

Growth    of   cancer,    limit- 
less,   149,     150 
of     malignant     tumors, 
rate   of,    182 

Gumma  of  the  tongue, 
mistaken  for  can- 
cer.   200,    419 

Guy's  Hospital,  London, 
statistics  of  autop- 
sies in,   76,   77 

"Habit  of  growth"  theory 
of  cancer  causa- 
tion, 116 

Habits  of  life,  influence 
of,  in  cancer  pro- 
duction, 61,  62, 
65,   69 

Hahnemann,    264 

Hamburg  Cancer  Labora- 
tory,  25 

"Hanbury,"   40 

Hand  ley's  permeation 
theory  of  cancer 
dissemination,  356- 
368 
surgical  technic  based 
upon,    356-368 

Hard   tumors,   135 

Harvard  University,  Can- 
cer Commission  of, 
6,    7,    29 


Harvey's  method  of  star- 
vation        ligature, 
372 
Hauser's    theory   of   can- 
cer causation,  115, 
110 
Head,    cases    showing   er- 
rors   in    diagnosis 
of  cancer  of,   196- 
199 
Headache     in     brain     tu- 
mors, relief  of,  by 
d  e  CO  mpressiou 
operation,  369 
Health,      general,      main- 
tonanco  of,  in  pre- 
vention  of  cancer, 
451 
Heart,     hypertrophy     of, 
accompanying     tu- 
mor,   173 
Heat  in  the  treatment  of 

cancer,   287 
Heating  of  cancer,  319 
Heidelberg    Cancer    Insti- 
tute,   8,    11 
Van  Helmont,  2 
Hemoglobin,  improve- 

ment in,  following 
trypsin  treatment, 
249 
Hemorrhage,    cancer    sus- 
pected   from,    188 
Hemorrhage,    control    of, 
by   ligation   of   ar- 
teries,    372,     383, 
384,  385,  386,  387, 
390 
due   to    cancer,    184 
due    to    local    applica- 
tions    in      cancer, 
427 
effect     of     radium     on, 

302 
following  use  of  injec- 
tio   trypsinij  249 
death    from,    186 
prevention    of,    in    op- 
eration for  cancer, 
351 
Hemostasis,       importance 
of,    in    arterial    li- 
gation, 394 
Herbs,    use    of,    in    treat- 
ment    of      cancer, 
264,  269 
Heredity,    bearing   of  ex- 
perimental investi- 
gations  on,   122 
influence  of,  on  cancer, 
48.     49.     96,     102, 
105,  450 
Heterologous     immune 

sera,   167 
Heterologous   inoculation, 
resistance  to,   166, 
167 
High-frequency       appara- 
tus    of     N  a  g  e  1  - 
Schmidt,   321 
High-frequency      currents 
in      treatment      of 
cancer,    308-326 
methods   of,    309-326 
Hildanus,    Fabricius,   2 
Hippocrates.    1,    106.    333 
History,  ancient,   1-4 
natural,  14 
of  cancer  patient.  13 
of    modern    cancer    re- 
search,   4-36 


522 


INDEX 


History     of     "starvation 
"ligature,"  372-37G. 
3.S3-3SG 
of    surgical    treatment 

of   cancer,    3 
special    cancer.    1S9 

Histological  appearances 
of  tumor  s,  134- 
13G,  137 

Histological  structures, 
constancy  and  va- 
riability of,  162, 
163 

Histological    study,    as 
basis,    for    surgical 
treatment    of    can- 
cer, 142 
value    of,    132-134 

Histologically  malignant 
tumors.  131 

Histopathological  exam- 
ination, supple- 
mented by  clinical 
examination,  181, 
187 

Histopathologv  of  cancer, 
130-143 

Hodenpvl's  ascitic  fluid, 
330,    341-343 

Hodgkin's  disease,  mis- 
taken for  cancer, 
218,    219 

Holadin  capsule,  247,  248 

Home,  lot  of  cancer  pa- 
tient at,  434,  435 

Homologous  immune 
serum,    171 

Homologous  immuniza- 
tion and  resist- 
ance, 166, 167-170, 
171 
induced  hv  normal  tis- 
sues, '  169-171 
induced       by       tumors, 

168-171 
natural,   167.   168 

Hornaday,  W.  T.,  53 

"Horn-core,"    48,    52 

Horse,    blood    serum,    330 

Horses,  cancer  in,  51,  52 

Hospitals,     cancer,     6,     7, 
25.    26. 
See     also     Institutions 
for     the     care     of 
cancer   patients 

Hot  towels,  use  of,  in 
operating  for  can- 
cer,  351 

House  of  Calvary,  N.  Y. 
City,  for  female 
incurable  cancer 
cases,  433 

Housing  advanced  cases 
of    cancer,    33 

Howard,  on  foundation 
of  cancer  depart- 
ment. Middlesex 
Hospital,  13,  14, 
18 

Human   blood  serum.   330 

Humeral  artery,  ligation 
of,  373 

Humoral  theory  of  can- 
cer, 106,  107,  144, 
145 
influence  of,  upon 
scientific  study, 
108-111 

"Humors,"   three,   1 

Hungary,  cancer  death 
rate   in,   73 


Huntington,  Collis  P., 
Memorial  Hospital, 
7 

Hydrocele    fluid,    331 

Hydroperitoneum  accom- 
panying abdominal 
cancer,  371 

Hygiene     in     prophylaxis 
of  cancer,  221 
in  treatment  of  cancer, 
3SS,    422.    42(! 

Hyperacidity  in  incurable 
cancer,    427 

Hypersensitiveuess,  176 

Hypertrophy.  differen- 

tiated from  tu- 
mor formation,  130, 
131 

Hypertrophy  of  organs, 
accompanying  tu- 
mor,   173,    174 

Hypertrophy  of  prostate, 
ligation  of  inter- 
nal iliac  arteries 
in,  373 
of  spleen,  ligation  of 
splenic  artery  in, 
373 

Hypogastric  arteries,  li- 
gation of,   373 

Hysterectomy  following 
arterial  ligation 
and  lymphatic 
block,    392 

Iceland,  cancer  in.  68.  69 
Iliac   veins,   avoidance  of 
injury  to.  in  arterial 
ligation.  394 
Immune      sera.      heterol- 
ogous. 167 
homologous,   171 
Immunity    to    cancer,    ac- 
tive,   125 
among  coal  miners,  81 
atreptic.    177,    178 
nature  of,  177 
racial.   62.  63.   69 
to    heterologous    inocu- 
lations,  166.   167 
Immunity   reactions,   165- 
176 
and   propagation,    bear- 
ing  of,    on    nature 
of  cancer,    161-177 
Immunization,  autologous, 
166 
dissemination      of. 
through    body.    178 
homologous,     166,     167- 
171.         See      also 
Homologous        im- 
munization, 
nature    of    change    ef- 
fected      bv,       171, 
172 
reaction   to  transplant- 
ed   tumors    follow- 
ing,   173 
Impacted     feces,     inflam- 
mation    of    cervix 
uteri     following, 
221 
Imperial  Cancer  Research 
Fund,   16-25  ;  also, 
10,   11,  27,   29,  33, 
146,    452 
attitude      of,      toward 
study      of      trans- 
planted     cancer 
cell,  154 


Imperial  Cancer  Research 
Fund,      extent     of 
work   of,   161 
investigations     of,     72, 

81,    82 
material  distributed  by, 

25 
objects  of,  16 
scheme   of,    17-25 
statistics    of,    84-87 
work      of,      on      tumor 
transference,    151 
Implantation     of     cancer 
cells    differentiated 
from  infection.  149 
Inadequacy     of    facilities 
for  care  of  cancer 
cases.   435-437 
Incandescent     light    in 
treatment    of    can- 
cer,  290,   291 
Incisions    for   cancer,    ex- 
tent  of.    352 
nature  of,    347 
Incurable   cancer,    inoper- 
able   and    irremov- 
able.  422-42S 
institutions     for,     429- 
437 
benevolent,    432,    433 
in  America,  431.  432 
in    Europe.    429-431 
private,  432 
"quack,"  433,  434 
operable    but    irremov- 
able,   421,    422 
use  of  radium  for.  300 
India,    cancer  in,    61,    63, 

66-68,  72,  82 
Indians,  North  American, 
cancer    among,    66 
Indigestion,     cancer     sus- 
pected from,  188 
ulceration    following 
persistent,    221 
Individuality     orf     cancer 
established    by    ex- 
perimental studies, 
147-148 
Indurated    mass  in    scalp 
caused    by    foreign 
body,  mistaken  for 
cancer,   196,   197 
Infections   in   fish,   55 
Infectious  diseases,  death 
rates     from,     com- 
pared  with   cancer 
death  rate,  93 
Infectiousness      of     vege- 
table tumors,  44 
Infectivity  of  cancer,  34, 
92,    94,    105,    118, 
123,   435,   450,   452 
in   light   of   propaga- 
tion     experiments, 
151-153 
possibility    of    trans- 
ference    no     proof 
of,   148,   149 
Inflammation,  absence  of, 
in     radium     treat- 
ment   of    growths, 
301 
chronic,  sources  of.  225 
Inflammatory       processes 
in     cancer     causa- 
tion, 112,   113 
Inflammatory      swellings, 
differentiated  from 
tumor      formation, 
130,    131 


INDEX 


523 


Inguinal  coloKtomy,  412 

Injectio  amylupsini,  ef- 
fects  of,    249 

Injection  of  the  teriuinal 
brancbos  after  ex- 
cision of  the  caro- 
tid artery.  377-871) 

Injury,    cancer   following, 
127 
to    breast    predisposing 
to  cancer,  226 

Innocent  tumors.  Hee  Be- 
nign   tumors. 

Inoculations,    autologous, 
175 
heterologous,  resistance 
to,    IGG,    167 

Inoperable     cancer,     422- 
428 
care  of  cases  of,  30,  33, 

432 
classification  of,   417 
thermoradiotherapy   in, 

320 
use     of     electrocautery 

in,   308 
usefulness     of     radium 
in,  300 

Inoperable  carcinoma  of 
breast,  sulphate  of 
radium  injection 
in,  302 
of  uterine  cervix,  ra- 
dium salts  treat- 
ment  for.   302 

Insects,  relation  of,  to 
vegetable  tumors, 
43 

Institute  for  Cancer  Re- 
search, the  Char- 
ity,  Berlin,    26,   29 

Institutional  care  of  in- 
curable cancer 
cases,    423 

Institutions    for    care    of 
cancer  patients, 
429-437 
benevolent,   432,   433 
in  America,  431,  432 
in  Europe,  429-431 
private,    432 
"quack,"    433,    434 

Institutions  which  com- 
bine clinical  and 
experimental  work, 
29 

Insurance  companies,  at- 
titude of,  toward 
alcohol,    81 

Internal      iliac      arteries, 
373 
ligation    of,    in    pelvic 
cancer,     383,     384, 
385,    386 
technic  of,   391 

International  Association 
for  Cancer  Re- 
search, 8,  9,  10, 
28 

International  conferences, 
8,    9,    10,    13 

Internes,  education  of,  in 
care  of  cancer  pa- 
tients, 31 

Intestinal  cancer,  in  In- 
dia,   68 

Intestinal  obstruction 
complicating  ovar- 
ian cancer,  424 

Intestinal  stasis,  lumpy 
condition       of 


breasts  duo  to, 
mistaken  for  can- 
cer, 202,   203 

Intestines,    cancer    of, 
death      rates     for, 
78.  79.  86 
relief  of,    421 

Intestines,  abnormalities 
of,  relief  of.  in 
connection  with 
arterial  ligation, 
389,  392 
polypoid     growths     of, 

130 
tumor  of,  thermoradio- 
therapy in,  310 

Intramural  spread  of  can- 
cer of  rectum,  366 

Investigation,  clinical  and 
laboratory,  36 
of  "quack   cures,"   261- 

276 
treatment  distinguished 
from,  35.     See  also 
Cancer  research. 

Ionic  sterilization  of  dis- 
eased foci  in  treat- 
ment of  cancer, 
324 

Ionic  surgery  in  treat- 
ment of  cancer, 
323,    324,   388 

Ireland,  cancer  death 
rate  in,  73,  90,  91 

Iron  chlorid  in  treatment 
of  cancer,  283 

Irradiation  of  tissues  by 
X-rays,   317 

Irremovable   cancer,    415- 
428 
classification     of,     415, 

417 
inoperable     and    incur- 
able,   422-428 
operable    and     curable, 

420,  421 
operable  but  incurable, 

421,  422 
seemingly,   418,   419 

Irritants,  influence  of,  in 
production  and  de- 
velopment of  can- 
cer, 48.  87.  See 
also   Irritation. 

Irritation,      chronic, 
sources  of,  225 
influence  of,    in    cancer 
causation,    67,    81, 
104,  111,  112,  113, 
123,  126,  127,  128, 
153,   154 
prevention    of,    follow- 
ing operation,  348, 
351 
relation    of,    to    cancer 
production   in  ani- 
mals,   160 

Italy,  cancer  death  rate 
in,  73 

Jacob  and  Geets'  bac- 
terial vaccine,  330 

Japan,  cancer  in,  63,  71, 
72,  82,  83 

Jaundice,   cancer  suspect- 
ed from,   188 
due    to    obstruction    to 
bile    passage    by 
cancer,    414 

Jaw,  cancer  of,  death 
rates   from,   78 


Jews,  cancer  in,  66,  95, 
90,  97 

Kangri  cancer,  67,  87, 
123 

"Kanker  boschje,"  3 

Kashmir,  See  Kangri  can- 
cer 

de     Keating-IIart's    dem- 
onstrations of  ful- 
guration  and  thor- 
moradi  o  t  h  c  r  a  p  y , 
New      York      Hkin 
and  Cancer  Hospi- 
tal,  312 
fulguration     apparatus, 
312 
instrumentation    and 
technic  of,  312-314 
method  of  treating  can- 
cer,  310-316 
See    also    Fulguration, 
thermoradiotherapy 
theory   of  thermoradio- 
therapy,   317-320 

Keratinization  in  propa- 
gated  tumors,    103 

Kidney,     cancer     of,     in 
swine,  52 
drainage  of,  413 
hypertrophy  of,  accom- 
panying   tumor, 
173 

Kidne.v  stone,  mistaken 
for  cancer,  205, 
207-208 

Kidney  tissue,  active  re- 
sistance induced 
by,    170 

"Knauer,"  45 

"Kohlhernie,"  40 

"Kook-koeck  en  Recepte 
Boek,"    2,    3 

"Kosher  wards,"  66,  96, 
97 

"Kropf,"    40 

Kromeyer  lamp  for  light- 
therapy,   290 

Laboratory  investigation, 
36 

Laparotomy,  exploratory, 
in  obscure  abdom- 
inal conditions, 
354 
importance  of,  204, 
210,  211,  212,  215, 
216 
for  arterial  ligation  in 
pelvic    cancer,    391 

Larynx,    cancer    of,    elec- 
trocoagulation     in 
treatment    of,    322 
tracheostomy  in,  412 

L  a  t  h  r  0  p  ,  Rose  Haw- 
thorne,   433 

Layman,  education  of, 
against  cancer, 
445-447 

Lead  as  filter  for  radium 
rays,    298,    301 
penetration  of,  by  beta 
and    gamma    rays, 
297 

Leeches,  in  treatment  of 
cancer,   2 

Legislative  investigation 
of  "cancer  cures," 
270-275 

Leipsic,  cancer  labora- 
tories of,  25 


5:2i 


INDEX 


I.cv>ni(las,   lOG 

l^L'tJiusy,      confusion      of, 

with    cancer,    1 
Leukocytosis,   accompany- 
ing cancer,  11)3 
during     trypsin     treat- 
ment, 241) 
Leukoplakia,   predisposing 
to       cancer,       120, 
224,   225 
Ligation,      arterial,      31. 
Hce    aluo    "Starva- 
.  tion   ligature." 
Ligation  and  exsection  of 
the    external   caro- 
tid artery  in  treat- 
ment of  malignant 
tumors    of    mouth 
and   face,    374-382. 
iSee     aluo     Carotid 
artery. 
Ligation    of    ovarian    ar- 
teries  with    double 
oophorectomy,    39 
of      vessels      following 
cancer      operation, 
351 
Ligature  material  for  use 
in     cancer     opera- 
tions, 331 
Ligatures,    knots  in,   mis- 
taken   for    cancer- 
ous nodules,  352 
Light,  electric,  with  eosin, 
in  treatment  of  cu- 
taneous cancer, 
291 
in  treatment  of  cancer, 
28S-29G 
arc  light,  289-290 
fluorescent      stimula- 
tion,   291 
incandescent,      2  9  0, 

291 
sunlight,    288-289 
X-rays,    291-296 
Light-therapy,    F  i  n  s  e  n 
lamp  for,  289 
Finsen-Reyn    arc    lamp 
for,   290 
Lime  with  sulphuric  acid 
in      treatment     of 
cancer,  285 
"Limitless"      growth      of 
cancer,     149,     150, 
178 
Linen,    use    of,    in    dress- 
ing cancer  wounds, 
353 
Linen    ligature    material, 

parafBned,   351 
Lingual    artery,     ligation 

of,   373 
Lip,  cancer  of,  136 
death  rate  for,  78 
due  to   smoking,   225 
electrocoagulation   in 

treatment  of,  322 
in  India,  07 
in  natives  of  Gilbert 
Islands,  68 
reported        cases        of, 
cured     bv     radium 
radiation,   300 
epithelioma  of,  case  of, 
191 
Lipoma,    139 

among   natives   of  New 

Guinea,  64 
of  breast,  mistaken  for 
cancer,  201,   202 


'  Liver,     canc(>r     of,     bile- 
stones      associated 
with,   227 
death    rates    for,    78, 

79,    80 
frequency        of,        in 

mammals,  ItiO 
in  sheep,  52 
in   swine,   52 
hypertrophy  of,  accom- 
panying        tumor, 
173,    174 
of    tortoise,    as    cancer 

"cure,"   3 
secondary    growths    in, 

141 
use     of,     for     inducing 
active      resistance, 
1G9 
Lizard,     case     of     papil- 
loma in,  55 
Locality,    cancer    mortal- 
ity    according    to, 
90,   91 
London,      cancer      death- 
rates  in,  92 
Cancer  Hospital,  440 
Radium  Institute,  302 
relation    of    overcrowd- 
ing   to    cancer    in, 
93 
Lotio      pancreatis,      247, 

248,   427 
Lumbar  colostomy,  412 
Lumpy        condition        in 
breasts   due   to  in- 
testinal    stasis, 
mistaken   for    can- 
cer, 202,  203 
Lung,   cancer  of,   case  of, 
424 
paracentesis  of  pleu- 
ra in,   421 
hypertrophy  of,  accom- 
panj'ing         tumor, 
173 
secondary    growths    in, 

141 
tumor  of,  thermoradio- 
therapy in,  316 
Lupus,      predisposing     to 
cancer,   224 
treatment       of,       with 
mesothorium,   304 
with  thorium  X.  304 
Lupus      erythematosus, 
malignant        new 
growths      superim- 
posed upon,   418 
Lupus      vulgaris,      malig- 
nant  new  growths 
superimposed     up- 
on, 418 
Lymphadenoma,      radium 
treatment  for,  299 
Lymphangioma,    139 
Lymphangioma      tuberos- 
e  u  m        multiplex, 
precancerous,   222 
Lymphangioplasty,       370, 
371 
contraindications      t  o, 

370 
relief    of    brawny    arm 
by,   421,    422 
"Lymphatic    block,"    case 
of,   214 
starvation    ligature 
and,    in    treatment 
of  cancer  of  pelvic 
organs,    383-411 


"Lymphatic  block,"   star- 
vation 1 i  g  a  t  ure 
and,  cases  of,  390- 
411 
technic   of,    392 

Lymphatic  glands,   malig- 
nant    growths     of, 
radium     treatment 
of,  298 
metastatic  sarcoma- 

tous.   X-ray    treat- 
ment  for,   296 
removal    of,    350,    351, 
352 

Lymphatic  permeation, 
140 

Lymphatic  system,  palli- 
ative ujeasuros  for 
cancer  applied  to, 
370,  371 

Lymphatic  vessels,  spread 
of  cancer  through, 
359 
twisting  of,  following 
operation  for  can- 
cer, 350 

Lymphatics,  spread  of 
cancer  cells 
through,  140,  141 

Lymphoma,    139 

Lymphosarcoma,     of    the 

neck,   erysipelas  as 

curative   agent   in, 

334 

radium    treatment    for, 

299 
treatment  of, 

with        mesothorium, 

304 
with  thorium  X,  304 

Lyttleton,  Hon.  Spencer, 
15 

Malignant  growths,  131 

among  inhabitants  of 
New  Guinea,  64 

clinical  distinction  be- 
tween benign  tu- 
mors and,  185,  186 

effect  of  small  doses  of 
X-ray  on,  294 

fluorescent  stimulation 
for,   291 

in   India,    67 

in  rats,  due  to  X-ray 
exposure,  294 

large  doses  of  X-ray  in 
treatment  of,  294 

R  i  V  i  6  r  e  method  of 
treating,  by  high 
frequency  spark- 
ing and  effleuve,309 

radium    treatment    for, 

298 

Malignant       papillomata, 

abdominal     drojisy 

accompanying,  371 

"Malignant,"        use        of 

term,  180,  181 
Mamma,    cancer    of,    fre- 
quency      of.       in 
mammals,    160 

in  cats,  51 

in   dogs,    50,    51 

in  mice,  heredity  and, 
100 
Mammary  arteries,  liga- 
tion of,  373 
Mammary  gland  ducts, 
case  of  obstruction 
of,  203 


INDEX 


525 


Manec's  paste  in  cauteri- 
zation of  cancer, 
284 

Manipulation,      care      In, 
34S.  349,  350,  352, 
363 
danger  of,  190 

Map,  McC'onnell's,  sliow- 
ing  proportion  of 
deaths  from  can- 
cer, 76,  91 
showing  state  of 
American  vital 
statistics,  1900, 
75 

Marsden's  paste  in  cau- 
terization of  can- 
cer,   2S4 

Massage.  See  Manipula- 
tion. 

Mastitis,  cancer  follow- 
ing,  226 

Mattel  "electricities"  for 
treatment  of  can- 
cer, 261-268 

Mattel  Investigation 
Committee,  266, 
267 

Meat,  relation  of,  to  can- 
cer,  82 

Medical  profession,  edu- 
cation of.  with 
reference  to  can- 
cer,  440-445 

Medullary  cancer,  case 
of,  in  python.  55 

Medullary   tumors,   135 

Melanotic    sarcoma,    case 
of  cure  of,  420 
permeation    theory    ap- 
plied to,  367,  368 

Menopause,  cancer  symp- 
toms attributed 
to,  216-218 

Mental     condition,     influ- 
ence  of.   in   cancer 
cases.   423-425 
cases   illustrating,   423, 
424 

Mesothorium  in  treat- 
ment of  cancer, 
283,   304.  305.   325 

Metabolism,  disturbance 
of,  in  cancer,  194 

Metaplasia.  138 

Metastases,       120.       124, 
125,  145.  146 
artificial  production  of, 

349 
effect  of  electrocautery 
treatment    on.    308 
effect  of  radium  treat- 
ment on,  301 
following    surgical    in- 
terference,        347, 
348,   349 
permeation    theory    of, 
361 

Metastatic  sarcomatous 
lymphatic  glands. 
X-ray  treatment 
for,   296 

Methods  of  investigation, 
comparison  of,  28, 
32,   33 

Methylene  blue  test  in 
urine  of  cancer  pa- 
tients. 192 

Metritis,  associated  with 
cancer  of  the 
uterus,    226 


Metritis,  chronic,  predis- 
posing to  cancer, 
127 

Mexico,    cancer  in,   60 

Micrococcus     neoformans, 
256.   257 
serum    from,    .'^20.    .•{.'52 
vaccine   fT-om,   ;;.'{(!.    .■',32 

Micro-orij;anisni,  theory  of 
cancer  due  to,   110 

Microscopic  diagnosis  of 
cancer,  190,  191, 
194 

Microscopical  appear- 

ances    of     tumors, 
134-137 

Microscopical  demonstra- 
tions of  facts  of 
transferring  can- 
cer.  150,  151 

Microscopical  study  of 
tumors,  value  of, 
132-134 

Middlesex  Hospital,  Can- 
cer Research  Lab- 
oratories of.  13- 
16,  29,  30,  33 

Milk,  effect  of  use  of, 
in  cancer  cases,389 

Mixed  toxins  of  Bacillus 
prodigiosus  and 
Streptococcus  ery- 
sipelatosus,  329, 
333.  335-337 

Mixed  tumor,  140 

Modified  operation  for 
cancer  of  breast 
based  on  permea- 
tion theory,  362- 
364 

Mohammedans,  cancer 

among.    67 

Molasses  in  treatment  of 
cancer,   259 

Moles,  predisposing  to 
cancer,  127,  222, 
223 

Mollusks.  tumors  in,  58, 
59 

Morosoff  Institute,  Mos- 
cow,   25 

Morphin,  in  treatment  of 
cancer,  effects  of, 
389 

Morphin  habit,  breaking 
of,  in  cancer  insti- 
tutions, 425 

Mortalitv     from     cancer, 
62,   77-79 
according     to     locality, 

90,  91 
habits  of  life  and,  65 
occupational,  80,  82 
See   also   Death-rate. 

Mouth,    cancer   of,    clean- 
liness in,  428 
death-rates   from,   78 
esophagostomy        in, 

412 
neurectomy  in,  369 
malignant     tumors     of, 
ligation    of    exter- 
nal   carotid   artery 
in.    374-382 

Mucor  muccdo.  serum 
from.  329.  332 

Mucor  racemnfus  inalig- 
nus.    2"3 

Mucous  membrane,  can- 
cer of.  operation 
for,  351,  352 


Muscle  fibers,  spread  of 
cancer  ccHh  along, 
140 

Mussels,  tumors  In,  58, 
59 

Mycosis  fungoides,  radi- 
um treatment  of, 
299 

Myeloma,    139 

Myoma,   139 

precancerous,   222 

Mysticism  invoked  to  ac- 
count for  cancer,  2 

Myxoma,    139 

Myxosarcoma,  case  of,  in 
a  white  raccoon- 
dog,   53 

Nagelschmidt's  high-fre- 
quenc.y  apparatus 
in  treatment  of 
cancer  by  diather- 
my,  320,  321 

Naso-oral  cavities,  can- 
cer of,  51 

Nasopharynx,  sarcoma  of, 
carotid  excision 
in,   420 

Natural  history  of  can- 
cer,   14 

Natural  resistance  to  tu- 
mor transplanta- 
tion.  167,   168 

Necrosis  of  rib  with  ab- 
scess mistaken  for 
cancer,   202 

Neck,  cancer  of,  treat- 
ment of,  based  on 
permeation  theory, 
364,  365 
lymphosarcoma  of.  ery- 
sipelas as  curative 
agent  in,  334 
sarcoma  of,  cured  by 
erysipelas,    335 

Necrotic  tissue,  discharge 
of,  facilitated  by 
arterial  ligation, 
388 

Negro,  cancer  in,  65,  66, 
91 

Nematode  infection  in 
mice,  153 

Nematodes.  in  cancer 
causation.  123 

Nephrotomy,  413 

Nervous  dyspepsia,  can- 
cer mistaken  for, 
211 

Nervous  gastralgia  simu- 
lating  cancer.    205 

Nervous  strain,  cancer 
and,   SO 

Nervous  system,  pallia- 
tive measures  for 
cancer  applied  to, 
369,  370 

Neurectomy.   369,   421 

Neuroma,   139 

Nevi,  development  of 
cancer  from,   223 

"New  medical  science," 
261 

New  Guinea,  cancer  in, 
64 

New  Netherlands,  cancer 
death-rate  in,  73 

New  York  Pkin  and  Can- 
cer Hospital,   431 
capacity  of,  for  cancer 
patients,   432 


526 


INDEX 


New  York  Skin  and  Can- 
cer Hospital.  Re- 
search Department 
of,  29-32 

New    York    State,    death- 
rate     from     infec- 
tious diseases  and 
cancer  in.  03 
first  to  establish   State 
institution     devot- 
ed   exclusively     to 
study  of  cancer.  5, 
6,   29 
Institute  for  the  study 
of    malignant    dis- 
ease,  r>,  C,   55,  50 
Research  Hospital  of,  6 

New  York  Zoological 
Par  k.  occurrence 
of  tumors  in,  53 

New  Zealand.  cancer 
death-rate  in,  73 

Nitric  acid  in  treatment 
of  cancer,  278, 
279,  2S1.  284 
local  use  of.  in  opera- 
tion for  ulcerating 
cancer,  350 

Nomenclature  of  tumors, 
138,    139 

Non-surgical  remedies, 
multiplicity  of.  3 

Non-surgical  treatment 
of  cancer.    277-344 

Normal  blood  serum.  330 

Normal  tissue,    active  re- 
sistance      Induced 
by,  169,   170,   171 
direct    descent   of    can- 
cer  from,   33 

Normal  tissue  in  treat- 
ment of  cancer, 
343 

North  America,  cancer 
in,   60 

North  American  Indians, 
cancer  among,  66 

Norway.  attitude  of, 
toward  cancer  con- 
ferences, 11 

Nose,  cancroids  of.  cured 
by  radium.   299 
obstruction    of.    due   to 
cancer,     relief     of, 
421 

Nosophen,  use  of,  in  can- 
cer,  428 

Nuclear    chromatin,    117 

Nurses,  education  of,  in 
care  of  cancer  pa- 
tients.  31 

Nutrition,  influence  of,  in 
goiter  in  fish.  58 
relation   of.    to    cancer, 
37,   40,    65 

Obstruction  of  alimen- 
tary tract  due  to 
cancer,  relief  of, 
421 
of  mammary  gland 
ducts,  case  of,  203 
of    bladder,     relief    of, 

421 
pyloric,  412 

Obturator  artery,  ligation 
of.  383,   392 

Occipital  branch  of  the 
carotid  artery,  in- 
jection of,  378, 
379 


Occupation,    effect   of,    in 
production  of  can- 
cer,  451 
influence  of,   in   cancer 
causation,  l'2i>. 

221 

Occupational  mortality 
from  cancer,  80-82 

Odontoma.   139 

Oesophagus,  cancer  of, 
death  rates  for,  78 

Ointment,    antiseptic,   use 
of,  in  cancer.  427 
use    of,    following    can- 
cer operations.  353 

"Olive    Knots."    43 

Oiiphorectomy.  double,  li- 
gation of  ovarian 
arteries  with.  391 

Operative  clinics  of  New 
York  Skin  and 
Cancer  Hospital, 
442 

Ophthalmoplasty,  follow- 
ing operation  for 
cancer  of  the  eye. 
369 

Opotherapy,   327.    343 
definition  of,   331 
use  of  term,   328 

Organotherapy,   331 

Origin  and  spread  of  can- 
cer,  140,  141 
theories  of,  145 

Oscillatory  desiccation  in 
treatment  of  can- 
cer,  322,   323 

Osteoma,  139 

among   natives   of  New 
Guinea,   64 

Osteosarcoma.    139 

Other  cancer  research  in- 
stitutions.  25-28 

Otoplasty,  following  op- 
eration for  cancer 
of  the  ear,  369 

Otto  Schmidt  serum  or 
vaccine,   252-256 

Oudin's  resonator  for 
high  -  frequency 
current  treatment 
of  cancer.  309 

Outlook,  the,  452-454 

Ovarian    artery,    ligation 
of,   383,  384,   386 
with    double    oophorec- 
tomy, 391 

Ovarian  cyst  accompa- 
nied by  cancer, 
case   of,    212 

Ovaries,  cancer  of,  case 
of.  424 
removal  of,  following 
arterial  ligation 
and  Ivmphatic 
block,   392.   393 

Ovary,  cancer  of.  death 
rate  from.  86 

Overcrowding,     goiter    in 
fish   due   to,   58 
relation    of.    to    cancer, 
92.    93 
Overfeeding,      goiter      in 
fish   due  to,   58 

Oxgall  and  sodium  oleate, 
258,  259 

Oxgall  compound.  247, 
248 

Oxid  of  uranium,  radio- 
active elements  in, 
297 


Oyster,  tumor  in,   59 

Pacific      Islands,      rarity 
of    cancer    in,    63, 
64 
Pagefs     disease,     predis- 
posing   to    cancer, 
226 
Pain,  absence  of,  in  early 
cancer        of        the 
breast,  182 
cancer   suspected   from, 

188 
in   cancer.  182 
in      incurable      cancer, 

control   of,    427 
relief    of,     hv     arterial 
ligation,  388.  390 
by    exjiosure   to    sun- 
light.  289 
by  phototherapy.  324 
by  surgical   methods, 
416 
Palliative    measures,    ap- 
plied     to      alimen- 
tary   system,    412, 
413 
applied    to    biliary   sys- 
tem,   414 
applied     to     lymphatic 

system.  370,  371 
applied  to  nervous  sys- 
tem. 369.  370 
applied    to    respiratory 

system,     412 
applied  to  urinary  sys- 
tem,   413,    414 
applied       to       vascular 
system.  372-411 
Palpation.      dangers      of, 

190 
Pancreas.        cancer        of, 
cholecystostomy  in, 
414 
Pancreatic  enzymes,  331. 
See     also     Enzyme 
treatment 
Papain    in    treatment    of 

cancer.   284 
Papilloma,   139 

among  natives  of  New 
Guinea,   64 
Papilloma,    case   of,   in   a 
lizard,   55 
development  of,  136 
Papillomata.      malignant, 
abdominal     dropsy 
occompanying.   371 
of  the  bladder,  136 
in  a  n  i  1  i  n  workers, 

81 
predisposing   to    can- 
cer, 127,   222 
Papillomatous      degenera- 
tion      of       uterus, 
tubes,    and   ovaries 
mistaken    for    sar- 
coma,  214,   215 
Paracelsus.  106 
Paracentesis     of     pleura, 

421 
Paracentesis  abdominalis, 

371 
Paraflin    for    carotid    in- 
jection. 378 
in  causation  of  cancer, 
126 
Paraffined    silk    or    linen, 

for  sutures,  351 
Paraffin-cancer      of      the 
skin,  136 


INDEX 


527 


Parasites,     vegetable     tu- 
mors due  to,  41 
Parasitic  origin  of  crown- 
galls,    42,    43 
Parasitic  theories,  40,  41, 
43,     44,     46,     107, 
117-121 
bearing    of    experimen- 
tal    investigations 
on,  122,  123 
Pare,    lOG 
Paste,  Plunket's,  3 
Pastes.     See  Caustics  and 

Escharotics. 
Pasteur    Institute,    Paris, 

26,   27 
Pearl  formation,  136 
Pectoral    muscles,    spread 
of     breast     cancer 
in,  357,  358 
Pelvic  organs,   cancer   of, 
case    of,    424 
starvation       ligature 
with  lymphatic 

block  in  treatment 
of,  383-411 
cases  of,  396-411 
cases  showing  errors 
in  diagnosis  of 
cancer  of,  216-219 
Penis,    cancer  of,    67 

in  horses,  51 
Penis,  cancroids  of,  cured 

by  radium,  299 
Pepsin    in    treatment    of 

cancer,   284 
"Pepule"       oxgall       com- 
pound, 247 
Perchlorid      of     iron      in 
treatment    of    can- 
cer,  284 
Perforation  of  the  corpus 
callosum    in    brain 
tumors,  370 
Perilymphatic         fibrosis, 
359 
brawny     arm     due     to, 
370 
Perineal  drainage,  421 
Periods    of    improvement 
from    cancer,    182, 
183 
Peritoneum,     closure     of, 
following      arterial 
ligation    and    lym- 
phatic block,  393 
incision      of,      for      ar- 
terial ligation,  391 
Permanganate    of    potas- 
sium in   treatment 
of  cancer.   427 
Permeation       theory       of 
cancer     dissemina- 
tion,  357-362 
applied     to     cancer     of 
the     stomach     and 
rectum,  364 
applied     to     cancer     of 

the  tongue,  364 
applied     to      melanotic 
sarcoma,  365,  367 
modified    operation    for 
cancer     of     breast 
based  on,  362,  363, 
364 
operability     of     cancer 
of   rectum    extend- 
ed  by,    365,    366 
surgical    technic    based 

upon,  356-368 
treatment  of  cancer  of 


tongue     and     neck 
based  on,  364,  365 
Peroxid    of    hydrogen    in 
treatment    of    can- 
cer,  427 
Persia,         attitude         of, 
toward  cancer  con- 
ferences,  11 
rarity  of  cancer  in,  63 
Perversion  of  cell  growth, 
in     production     of 
cancer,   54 
Peru,  attitude  of,  toward 
cancer      confer- 
ences, 11 
Pcyrilhe,  106 
Phagedenic  chancres,  ery- 
sipelas as  curative 
agent  in,  334 
Pharynx,   cancer  of.   elec- 
trocoagulation   i  n 
treatment    of,    322 
esophagostomy        in, 

412 
gastrostomy  in.  412 
Phenacetin    for    relief    of 
pain  in  cancer,  427 
Phosphorus  with  arsenic, 

284 
Phototherapy      in      treat- 
ment     of      cancer, 
287     324 
Physiotherapy,    287-326 
"Physicians'    Pocket    Ref- 
erence   to    the    In- 
ternational List  of 
Causes    of   Death," 
75 
Pigmented  moles,  precan- 
cerous,     222.     See 
also  Moles. 
Pistacia  terebinthus,  257, 

258 
Pitch-blende,    radio-active 

elements  in,   297 
Plant    tumors.      See    Bo- 
t  a  n  i  c  a  1     Distri- 
bution 
Plasma    cells,    excess    of, 
during     immuniza- 
tion, 173 
Plasmodiophora     hrassic(B 
in     production     of 
vegetable     tumors, 
40,    44 
inoculation   of   animals 
with,   41 
Plastic       procedures       in 

cancer,    368,    369 
Platinum     as     filter     for 

radium  rays,  301 
Pleura,    cancer    of,    para- 
centesis in,  421 
Pleural      adhesion.      tho- 
racic       dissemina- 
tion  of  cancer   de- 
layed  by,   361 
Pleuritic        fluid,        with- 
drawal      of,       in 
cancer    of    breast, 
371 
Pleuritic   transudate,   331 
Plunket,   3 
Polonium,     discovery    of, 

297 
Polypoid    growths    of   in- 
testines,      rectum, 
and   uterus.   136 
Polypus,   139 

uterine,     mistaken     for 
cancer,  216 


Possibilities     of     clinical 
and      experimental 
work,  32 
Post-mortem  examina- 

tions,     importance 
of,      in      compiling 
cancer       statistics, 
76 
Post-natal      displacement 
theory    of    cancer, 
114 
Postoperative         fulgura- 
tion,  326 
cases  of,  238,  2.39 
Postoperative    permeation 
nodules,     effect    of 
X-ray  on,   324 
Potassium   bichromate   in 
treatment    of    can- 
cer,   279,    283,    284 
Practical    results   of   can- 
cer   research,    144- 
154 
Precancerous     conditions, 

127,    222-224 
Predisposing      causes      of 
cancer,   122-129, 
220,    221 
cases   illustrating,    228- 

236 
in    production    of    can- 
cer,   451 
"Premetastatic       period," 

349 
Pressure     symptoms,     re- 
lief of,   421 
by    arterial    ligation, 
388,    390 
Prevention       of       cancer. 

See  Prophylaxis. 
Prevention       of       cancer, 
surgical    treatment 
and,  353 
Private     institutions    for 
care  of  cancer  pa- 
tients,  432 
Prolapse    of   left    lobe   of 
liver        simulating 
cancer,  205 
Prolonged        propagation, 
criticism    of    value 
of.   158-160 
Propagation      of     cancer, 
experimental,  bear- 
ing   of,    on    nature 
of  cancer,    161-177 
criticism    of    value    of. 

154-158 
infectivitv   in   light   of. 

151-153 
justification     of,      148- 

154 
opportunities      afforded 

by,   178 
prolonged,    criticism   of 

value  of,    158-160 
surgical  treatment  jus- 
tified b.v,   151 
Prophylaxis,  220-236 
environment.  221.  222 
illustrative    cases,    228- 

236 
local  manifestations  of 
other  diseases,  224 
precancerous     c  o  n  d  i- 

tions,    222-224 
sources    of    chronic   in- 
flammation and  ir- 
ritation. 225-228 
surgical  treatment  and, 
I  353 


528 


INDEX 


Prostate,  cancer  of.  cys- 
tostomy  of.  413 

rrostatic  hypertrophy, 
ligation  of  inter- 
nal iliac  arteries 
in,  373 

I'rotozoa.  in  production 
of  cancer.  41 

Prussia,  cancer  death 
rate   in,    73 

I'soriasis,  predisposing  to 
cancer,    21i4 

Psoriasis  lingua;,  predis- 
posing to  cancer, 
224 

Public,  education  of,  in 
prevention  of  can- 
cer. 445-447 

Pul)licity  methods  in  the 
campaign  of  educa- 
tion against  can- 
cer,   447,    448 

Pulsating  aorta  simulat- 
ing cancer.  205 

Pulsating  tumor,  ligation 
of  internal  iliac 
artery  in,  373 

Puppies,  boiled,  as  can- 
cer   "cure,"    3 

Purges,  drastic  use  of, 
contraindicated  in 
incurable  cancer, 
426 

Pus,  discharge  of.  facili- 
tated bv  arterial 
ligation.   3.SS 

Pyloric  obstruction  due 
to  cancer,  gastro- 
enterostomy i  n  , 
412 

Pyloric  stenosis  simulat- 
ing cancer.  205 

Python,  tumors  in,  55 

"Quack"  cancer  institu- 
tions.   433,   434 

Quack    "cures"    for    can- 
cer. 261-27(1.   446 
use  of  radio-active  sub- 
stances in,   305 

Quartz  mercury  vapor 
lamp  for  light- 
therapy,    200 

Quinin  with  X-rays  or 
radium  in  treat- 
ment of  cancer, 
291 

Raccoon-dog.  wild,  case  of 
neoplasm  in,  53 

Racial  immunitv  to  can- 
cer.  62,    63.    69 

Radical  abdominoperineal 
operation  for  can- 
cer of  the  rectum, 
365,    360 

Radio-active  gelatin.  305, 
306.    388 

Radio  -  active  substances 
in  treatment  of 
cancer,    325 

Radio-activity,  rOle  of,  in 
cancer  due  to 
smoking,   225 

Radiodermatitis.  destruc- 
tive ulcerative,  in 
rats,  due  to  X- 
rays,  293 
produced  by  high-fre- 
quency currents, 
319 


Radiosensitiveness  of  tis- 
sues, diflferences  in, 
31S 
effect     of     temperature 
on,    319 
Radiotherapy    in    cancer, 
287 
combined   with   surgery 
in      treatment      of 
cancer,   325 
Radiothorium,   304 
Radium,  297-304 
Radium,       discovery      of, 
297 
emanation  of,   297 
estimated      energy     of, 

303 
in  treatment  of  cancer, 
277,    283.    297-304, 
325,  38S 
apparatus  for,  298 
Radium,    presence    of,    in 
cancer    tissue,    126 
use  of,  as  prophylactic 
measure  after  can- 
cer operations,  300 
Radium  A,  297 
Radium  B,   207 
Radium      bromid,      mini- 
mum    amount     of, 
in      cancer      treat- 
ment, 302 
Radium   rays,   297 

action  of.  on  malignant 
growth,  301 
Radium     rays,     filtration 
of,    299,    301 
introduction     of.     into 
center     of     tumor, 
299,  300 
removal     of     injurious 
elements      from, 
technic  of,   299 
rules     for     application 
of,    302 
Radium  salts,  small  doses 
of,  in  cancer  treat- 
ment,   302 
Radius,     sarcoma     of.     li- 
gation   of  humeral 
artery  in,  373 
Rate  of  growth  in  malig- 
nant tumors,  182 
Receptors,   329 
Rectum,    cancer    of,    case 
of,  213 
cleanliness  in,   428 
death    rates   for,    78, 

79,    86 
electrocoagulation   in 
treatment    of,    322 
operability      of,      ex- 
tended by   permea- 
tion    theory,     365, 
366 
permeation  theory  of, 

364 
spread  of,  366 
polypoid     growths     of, 
136 
Rectus     sheath,     removal 

of,    362 
Recurrence    of    cancer 
after    surgical    in- 
terference,     3  4  7, 
348 
after    earlv    operation, 

346,   347 
after      incomplete      re- 
moval, 354,  355 
of  breast,  358 


Recurrence  of  cancer  of 
breast  reduced  by 
operation  based  on 
permeation  theory, 
362 
of  face  and  mouth,  pre- 
vention of,  by  ex- 
cision of  both  ex- 
ternal carotids, 
380 
of  rectum,  after  radi- 
cal abdominoper- 
ineal operation, 
365 

Registration,  death  and 
birth,  importance 
of.  75,  77 

Reproduction  of  normal 
structure,  in  tu- 
mor formation,  131, 
134 

Reproductive  system,  can- 
cer   of,    79,    86 

Reptiles,  cancer  in,  54, 
55 

Research,  modern  history 
of,   4-36 

Research,  institutions  for, 
r,-S2 

Resemblance  of  crown- 
gall  in  plants  to 
canrer,   41-46 

Residue,  Vaughan,  330, 
339,    340 

Residues,      definition     of, 
330,  331 
In  treatment  of  cancer, 

338-341 
use   of  term,   328 

Resistance,  loss  of  power 
to  induce,  175,  176 
varying  powers  of  tu- 
mors to  induce, 
179 
See  also  Active  resist- 
ance. 

Respiratory  difficulties 
due  to  cancer,  184 

Respiratory  system,  pal- 
liative measures 
applied  to,   412 

Retina,   cancer  of.  127 

"Return  after  removal," 
185,   186 

Rheumatism  diagnosed  as 
recurrent  cancer, 
444 

Rhinoplasty  following  op- 
eration for  cancer, 
368.  369 

Ribbert's  theory  of  can- 
cer causation.  114 

Rivi&re  method  in  treat- 
ment of  cancer, 
309 

Rockefeller  Institute,  can- 
■    cer    department.    26 

Rodent  ulcer.   136,  137 
among  natives  of  Now 

Guinea,  64 
effect   of   radium   treat- 
ment on,  303 
precancerous,    222 

Rodman  operation  for 
breast  cancer,  363 

Rontgen  rays.  See  X- 
rays. 

Round-celled  sarcoma  of 
the  nasopharynx, 
carotid  excision  in, 
420 


INDEX 


529 


Roynl  Cancer  Hospital, 
Glasgow,   25,   4:U 

Koyal  Institute  of  Ex- 
perimental Thera- 
peutics, Frankfort- 
on-Main,    8 

Royal  Prussian  Institute 
o  f  Experimental 
Therapeutics,  27, 
29,    146 

Rubber  drainage  tubes, 
351.    363 

Rubber    tissue,     substitu- 
tion of,   for  drain- 
age  tubes,   351 
use  of,  in  dressing  can- 
cer wounds,  353 


Sacra  media,   ligation  of, 

386,  392 
St.    Louis    Cancer    Hospi- 
tal,   26 
St.  Rose's  Free  Home  for 
Incurable     Cancer, 
New      York     City, 
433 
Salmon   trout,    cancer  in, 

55 

Salol   for    relief   of    pain 

In  cancer,  427 

use     of,      in     breaking 

morphiri  habit,  425 

Salt-free    diet   in    cancer, 

426,  427 
Salts    of    uranium,    pene- 
trative     rays      in, 
297 
Salvarsan     in     treatment 

of  cancer,  283  . 
Samariter    Haus,    Heidel- 
berg, 8,  11,  25,  28, 
29,   431 
Sanitas,   in   treatment   of 

cancer,   427 
Sapremia,  leading  to  diag- 
nosis   of    irremov- 
able cancer,  419 
Sarcocele    of    testicle,    li- 
gation     of      sper- 
matic   arteries    in, 
373 
Sarcoma,    case    of,    cured 
by  erysipelas,  334, 
335 
Sarcoma,   132.  139 

among  natives  of  New 

Guinea,  64 
development    of,     from 
carcinoma,      16  4, 
165 
differentiation       from 

carcinoma,    112 
effect    of    Coley's    fluid 

on,  337 
in    domesticated    fowl, 

54 
in   India,   67 
injection  of  hot  serum 

in,    319 
melanotic.      See    Mela- 
notic sarcoma 
of   buttock   ligation    of 
internal    iliac    ar- 
tery   in,    373 
of  face  and  mouth,   li- 
gation   and    exsec- 
tion     of     external 
carotid    artery    in, 
380 
of    nasopharynx,    caro- 
tid excision  in,  420 


Sarcoma,  of  radius,  lip;a- 
tion      of     humeral 
artery    in,    373 
of     skin,      development 
of,  from  benign  le- 
sions,   223 
papillomatous    degener- 
ation    of     uterus, 
tubes,   and  ovaries 
mistaken  for,  214 
radium    -    sensitiveness 

of,   318 
radium    treatment    for, 

299 
treatment  of,  with  Co- 
ley's      Fluid.      See 
Coley's   Fluid 
treatment       of,       with 
mesothorium,  304 
with  thorium  X,  304 
with  X-ray,  295 
transplantation  of,  150 
Scalp,       epithelioma      of, 
mistaken       for 
syphilis,    197,    198 
indurated  mass  in,  due 
to     foreign     body, 
mistaken    for    can- 
cer, 196,  197 
Scar,  case  of  epithelioma 
developing  in,   229 
development    of    cancer 

in,    127,    223 
following         operation, 
prevention  of  irri- 
tation   by,    348 
Scar-tissue,   reduction   of, 
to       minimum      in 
cancer    operations, 
^52 
Scirrhus     of    the    breast, 
135 
case   of,  in   Tarawa,  68 
Scirrhus    tumors,    135 
Schmidt    serum    or    vac- 
cine,  252-256 
Schmidt's         JahrMcher, 


Sclerosis  of  stomach  sim- 
ulating cancer,  205 
Scotland,      cancer     death 

rate  in.  73 
Scrotum,     cancer     of,     in 
chimney    -   sweeps, 
81,    126 
Sebaceous   cyst,    aberrant 
thyroid      mistaken 
for,   198.  199 
Sebaceous    differentiation 
in  transplanted  tu- 
mors,   163 
Secondary    growths,    141, 
184 
death    from,    186 
Sections,    method    of    ob- 
taining  and  exam- 
ining    prior     to 
1875.     138 
Sedation,    the   watchword 
in      cancer      treat- 
ment, 286 
Selenium   in   treatment  or 

cancer,    286 
Sensitization     of     tissues 
bv  fulguration,  317 
Sepsis,    in    pelvic   cancer, 

388,    389 
Septicemia      leading      to 
diagnosis    of    irre- 
movable cancer, 
419 


Sern.      immune,      heterol- 
ogous.   167 
Serotherapy,  .",27-338 

definition    of,    328,    329 

Serous    exudates,     and 

body     fluids,     330, 

.",31 

in  treatment  of  cancer, 

341-343 
use  of  term,   328 
Serum,    antitoxic,    defini- 
tion   of,    329 
blastomycetic  antitoxic, 

3.32 
blood,'  3.30,    331 
of  donkey,   331 
of  horse,    330 
of  human,   330 
cytolytic,    of   Von    T.ey- 
den    and    Blumen- 
thal.  328 
Doyen's,  256,  257,  329, 

332 
from   birds  of  prey,  in 
treatment    of    can- 
cer.  251 
Serum.    Hodenpyl's,    341- 
343 
homologous,  171 
of    Emmerich     and 

Scholl,   329.   332 
Schmidt's,  252-256,  329, 

332 
Wlaeff's,   329,  332,   333 
Serum       reactions,       pro- 
posed,     for      diag- 
nosis     of     cancer, 
193,  194 
Serodiagnosis,    191,    192. 

193,  194 
Serodialyzation     test     of 
Abderhalden.       ap- 
plied     to      cancer. 
194 
Servia.  cancer  death  rate 

in,   73 
"Settling    down"     period 
of    advanced    can- 
cer   patients,    424, 
425 

death     rates     from 
cancer      in      each, 
78,  79 
increase    of    cancer    m 
each,  89 
Sex  constitution,  in  com- 
pilation   of    statis- 
tics,  72,   73 
Sex   incidence   of    cancer, 

78.   79,   83,   104 
Sheep,   cancer  in.   52 
Shock  in   breast  amputa- 
tion. 362 
in   carotid  ligation,   ex- 
cision,   and    injec- 
tion. 382 
"Short-circuiting"    opera- 
tion,   413.    421 
Side-chain  theory  of  Ehr- 

lich,  329 
"Sideration"      in      treat- 
ment    of     cancel-, 
311 
Sigmoidostomy,    412 
Silver  in  filtration  of  ir- 
ritant rays,   298 
Silver    nitrate    in    treat- 
ment of  precancer- 
ous   ulcer,    279 
Sinuses.         cancerous 
changes  in,    127 


Sex, 


530 


INDEX 


Site    of   grafting    tumors, 
examiuation       o  f , 
172,    173 
Site  incidence,   50 
in  bovlnes,  32 
in    calculation    of   can- 
cer death  rate,  77- 
79 
in    cats,    51 
in    compilation    of   sta- 
tistics,   S4-S7 
in  dogs,  50,  51 
in   horses,   51,  53 
in  Iceland,  69 
in   India,  07,  68 
in    Jews    and    Gentiles, 

97 
in  Kashmir.     See  Kan- 

gri  cancer 
in   sheep,   52 
in  swine,   52 
Size  of  tumor  in  relation 

to   danger,    182 
Skin,      active      resistance 
induced   by,    170 
cancer    of,     caused    by 
X-rays,    292 
death  rate  for,  86 
electrocoagulation    in 
treatment    of,    322 
fluorescent      stimula- 
tion for,   291 
in  cats,  51 
in  dogs,   50 
in  swine,  52 
epithelioma   of,    cauter- 
ization    as     treat- 
ment for,   285 
light-therapy  for,  290 
X-ray  treatment  for, 
285 
erythema     of,     due     to 

radium  rays,   301 
hyperemia  of,  produced 
by     the     F  i  n  s  e  n 
light,  290 
malignant    growths    of, 
radium      treatment 
of,    298 
paraffin      and      arsenic 

cancer  of,  136 
sarcoma     of,      develop- 
ment  of,    from   be- 
nign   lesions,    223 
stimulation    of,    by    ex- 
posure   to    actinic 
rays,   290 
Skin    incision    in    operat- 
ing for  cancer,  ex- 
tent  of,    352 
Skin-grafts,  following  op- 
eration for  cancer, 
352,  368 
Smoking,    cancer    due    to, 

225 
Soap   solution   of   sodium 
oleate  and  ox-gall, 
258,  259 
Society    for   the   Erection 
of     Hospitals      for 
Cancer       Patients, 
Vienna,  431 
Sodium     oleate     and    ox- 
gall,  258,   259 
Soft  tumors,   135 
Soil,  influence  of.  in  can- 
cer   causation,    61, 
69,    128 
Solar  arc  lamps,  289,  290 
Solar-therapy    in    cancer, 
288 


Soot,      in      causation     of 

cancer,   126 
South  America,  cancer  in, 

60 
South    Sea    Islands,    can- 
cer   in,    60 
Spain,   cancer  death  rate 

in,  73 
Special      cancer      history 

blank,    188,    189 
Speciflc  serum,   definition 

of,    329 
Spermatic    arteries,    liga- 
tion   of,    373 
Spermatocele    fluid.    331 
Spleen,     hypertrophy     of, 
accompanying     tu- 
mor,   173,    174 
ligation     of     splenic 
artery    in,    373 
use     of,     for     inducing 
active     resistance, 
169 
Splenic     artery,     ligation 

of,    373 
Sponging      cancerous 
wounds,  method  of, 
352 
Spontaneous  healing,  150, 

172,   186 
Spread    of    cancer    cells, 
140,    141 
process   of,    183,    184 
Spurge,    burnt,    with    ar- 
senic, 284 
Squamous    epithelium    of 

the   tongue,    136 
Stafford,      Mrs.      Alithea, 
endowment  of  can- 
cer  department   of 
Middlesex      Hospi- 
tal, 15 
Starvation,    due    to    can- 
cer,   184 
"  Starvation        ligature," 
case    of    use    of, 
424 
history   of,    372-374 
in  treatment  of  tumors 
of  mouth  and  face, 
374-382 
indications  for,  379 
ob.1ections     to,      380, 

381 
summary    of    results 

of,   381.    382 
technic  of,  376-379 
with    lymphatic    block, 
in      treatment      of 
cancer     of     pelvic 
organs,    383-411 
cases  of,   396-411 
clinical       application 

of,    394.    395 
history  of,  383-386 
indications    for,    390 
objections     to,     389, 

390 
purposes  of,  386-388, 

389 
technic   of,    391-394 
Statistical     studies,     sig- 
nificance and  value 
of,  70,  71 
summary    of,    104,    105 
Statistics,      difficulty      in 
collection     of,     71, 
72,  102,  103 
errors  in  compiling,  72, 
73 
Statistics,    extent    of,    3S 


Statistics,  correct  and  in- 
correct     diagnosis 
of   cancer  in   Lon- 
don Hospital,  195, 
196 
fallacies    in    American 
method   of   compil- 
ing, 73-76 
importance  of  autopsies 
in     compiling,     76. 
77 
in   Iceland,   69 
in   India,   67 
is     cancer     increasing, 

82-90 
mortalit.v,   77-79 
according    to    localitv, 

90,    91 
of  occupational  mortal- 
it.v    from     cancer, 
80-82 
relation  of,  to  etiology, 

91-104 
universality    of    cancel' 
shown    by,    72 
Sterilization      of     instru- 
ments,   importance 
of,  346 
Stomach,  cancer  of,  death 
rates    for,    78,    79, 
86 
due  to  irritation,  227 
following    ulcer,    127 
gastrostomy   in,    412 
gastro  -  enterostomy 

in,  412 
permeation  theory  of, 

364 
See  also  Gastric  can- 
cer, 
obstruction     of,     relief 
of,    421 
"Stomach     trouble,"     due 
to  pyloric  stenosis, 
mistaken    for    can- 
cer,  205,   207 
Stomatitis,   ulceration  fol- 
lowing    persistent, 
221 
Stone     in     kidney,     mis- 
taken   for    cancer, 
205,    207,    208 
Streptococcus      erysipela- 
tosus,  serum  from, 
329,  332 
Streptococcus      eriisipela- 
tosus  and  Bacillus 
prodigiosus   toxins, 
329,  333,  335-337 
Streptococcus  toxins,  333 

Wyeth's,    329,   333 
Stuttgart,  relation  of 
overcrowding        to 
cancer    in,    93 
Subcutaneous   tissue,   ma- 
lignant growths  of, 
radium     treatment 
for,   298 
Sulphate    of    radium,    in- 
.icctions    of,    in   in- 
operable carcinoma 
of  breast,  302 
Sulphate  of  zinc  in  treat- 
ment     of     cancer, 
282 
Sulphur,      ingredient     of 
Plunket's    paste,    3 
Sulphuric    acid    in    treat- 
ment    of      cancer, 
278,  279,  281,  283, 
285 


INDEX 


531 


Sunbaths  in  treatment  of 

cancer    288 
Sun-gla?s.      use      of,      in 
treatment    of    can- 
cer,   288,    289 
Sunlight  in   treatment  of 
cancer,  288,   289 
with     eosin     in     treat- 
ment of  cutaneous 
cancer,  291 
Superficial  tumors,   meso- 
thorium    treatment 
of,  304 
Superfatted  soap  and  ox- 
gall,  259 
Superior      maxilla,      car- 
cinomata  of,  cured 
by  radium,  299 
Surgical  treatment,  based 
upon     "permeation 
theory"      of      dis- 
semination, 356-368 
for   cancer   of  breast, 

362-364 
for     cancer     of     the 

rectum,   365,  366 
for  cancer  of  tongue 
and  neck,  364,  365 
for      melanotic     sar- 
coma,  367,  368 
Surgical  treatment,   basis 
of,     141,    142 
by    plastic    procedures, 

368,  369 

contraindications   for, 

in    epithelioma    or 

skin,   285 

factors  determining,  356 

general  technic  of,  345- 

355 
history  of,   3,   4 
improvements   in,   34 
justification  of,  178 
justified     by     propaga- 
tion     experiments, 
151 
palliative  measures,  ap- 
plied to  alimentary 
system,  412,  413 
applied      to      biliary 

system,    414 
applied  to  lymphatic 

system,   370,   371 
applied     to     nervous 

system,   369,    370 
applied     to     respira- 
tory system,  412 
applied     to     urinary 

system,    413,   414 
applied    to    vascular 
system,  372-411 
preliminary  to  fulgura- 

tion,   314 
purposes  of,   353-355 
special  technic  of,  356- 
414 
Surgery    in     combination 
with   radiotherapy, 
325 
Swine,   cancer  in.   52 
Switzerland,  cancer  death 

rate  in,  73 
Symbiosis,   119 
Syphilis,  diagnosed  as  ad- 
vanced cancer,  444 
Syphilis,     epithelioma    of 
scalp  mistaken  for, 
197,    198 
malignant  new  growths 
superimposed  upon, 
418 


Syphilis,   predisposing  to 
cancer,  224,   225 
relation    of,    to   cancer, 

94,   95 
simulating  cancer,  205, 
208,    209 
Sweating  in    cancer,   con- 
trol of,  427 

"Tampering,"  results  of, 
238 

Tapping  for  ascitic  fluid 
in  abdominal  can- 
cer, 371 
for  pleuritic  fluid,  in 
cancer  of  the 
breast,    371 

Tar,  in  causation  of  can- 
cer,   128 

Tarawa,    cancer   in,    68 

Tartar    emetic    in    treat- 
ment    of      cancer, 
279,    285 
with    sulphate   of   zinc, 
282 

Teeth,  decayed,  cancer 
due  to  irritation 
from,  226 

Temperature,  effect  of,  on 
cancer  cells,  321 
on  radiosensitiveness 
of   tissues,   319 
elevation     of,     in     dia- 
thermy,   320 

Tension  on  wound  fol- 
lowing operation, 
avoidance    of,    351 

Teratoma,    123,   139 

Terchlorid  of  antimony 
in  treatment  of 
cancer,    285 

Terminal  branches  of 
carotid  artery,  in- 
jection of,  377-379 

Testicle,  sarcocele  of,  li- 
gation of  sper- 
matic arteries  in, 
373    . 

Testis,  use  of,  for  pro- 
ducing active  re- 
sistance,  170 

Thames  Valley,  cancer  in, 
61 

Theoretical  results  of 
cancer  research, 
154-160 

Theories  of  cancer  etiol- 
ogy.    See  Etiology. 

Theories  of  the  ancients 
concerning  cancer, 
1 

Theories  of  treatment, 
new,  for  cancer, 
445 

Thermic  coagulation,  388, 
424,   427 
following  arterial   liga- 
tion      with       lym- 
phatic   block,    393 

Thermopenetration  i  n 
treatment  of  can- 
cer.   316.   317,    416 

Thermoradiotherapv,  314, 

317-320.    325.    326. 

388.   416.   422,  424 

activity     of     rays     in, 

317,    318 

de       Keating  -  Hart's 

theory  of.    317-320 

in  tumor  of  brain,   316 

in   tumor   of  lung,    316 


Thermoradiotherapy,     i  n 
tumor    of    intes- 
tines, 316 
in  tumor  of  uterus,  316 
technic  of,  319 
Thickening   of   abdominal 
muscles  simulating 
cancer,    205 
Thierscli's  theory  of  can- 
cer causation.  111, 
112 
Thoracocentesis,    371 
Thoremiden  in  treatment 

of  cancer,  285 
Thorium,  304 
Thorium    paste    in    treat- 
ment    of      cancer, 
285 
Thorium    X   in    treatment 

of   cancer,    304 
Thymus  gland  extract,331 
Thyroid    cancer,    136 

in   fish,    55-57 
Thyroid    extract,    sheep's, 

331 
Thyroid  tumors.  131,  132 
Tight   lacing,    cancer   due 

to,  227 
Tomatoes,  supposed  influ- 
ence  of,    in    causa- 
tion of  cancer,  128 
Tongue,    cancer    of,    case 
of,   in   Tarawa.    68 
death    rates   from,  78 
due  to   smoking,   225 
early    stage    of,    181, 

182 
electrocoagulation   in 
treatment    of,    322 
esophagostomy      i  n , 

412 
in    India,    67 
ligation     of     lingual 

artery    in,    373 
permeation  theory  of, 

364 
treatment    of,    based 
on      permeation 
theory,   364,  365 
value   of  histological 
study  in,   133.   134 
carcinomata  of,  radium 
treatment  for.  299 
cases     showing     errors 
in      diagnosis       of 
cancer   of.    199-201 
epithelioma  of,   radium 
treatment    of,    302 
gummatous  involve- 

ment of,    mistaken 
for  cancer,  419 
Tonics    in    treatment    of 

cancer,    422,    426 
Tonsils,    cancer    of,    elec- 
trocoagulation     in 
treatment    of.    322 
Tortoise,      liver      of,      as 

cancer    "cure."'    3 
Tourniquets.        avoidance 

of  use   of,    352 
Toxemia   as  result  of  ra- 
dium treatment  of 
malignant   growth, 
301 
Towns,  frequency  of  can- 
cer   in.    90 
Toxins,    mixed,    of   Strep- 
tococcus  eriisipela- 
tosus  and  Bacillus 
prodiaiosus,       329, 
333,    335-337 


532 


INDEX 


Toxins,  use  of  torni.  328 
Wvetli's     streptococcus, 
329.  333 
Triiclicostoniy,    412.    421. 
Tracsferoncf    of     canc'cr. 
niicroscopicnl  dem- 
onstration of  facts 
of,    ir)0.    ir.l 
no  proof  of  infcctivit.y, 
14S,  149 
Transplantation.    difTeron- 
tiated    from   infcc- 
.tion,  123 
loss    of    power    to    in- 
duce    '     resistance 
and   acquisition   of 
powers  of  continu- 
ous growtli  follow- 
ing,   175,    176 
microscopical       demon- 
stration    of     facts 
of,    150,    151 
similarity    of.     to    me- 
tastasis,   T40 
site   of.    172,    173 
variability  of  structure 

in,   102.  1()3 
varying   results    follow- 
ing,  174,   175 
Transplantation,  ureteral, 

413,    414 
Transtbermy      in      treat- 
ment     of      cancer, 
320,  321 
Treatment : 

Aesiah    cancer   cure  in, 

270,    271 
alto-frequent    cytolysis, 
alto-frequent    scin- 
tillation.     efBeuva- 
tion,  etc.  (Rivi&re) 
in,    309,    310 
arc    light   in,    2S9.    290 
based     on     permeation 
theory   of   dissemi- 
nation, 350-3(i8 
biotherapy    in.    327-344 
bipolar      voltaization 
(Doyen)    in,   322 
Cardigan     "cures"     in, 
268-270 
cataphoresis     in,     323, 

324 
caustics   or   escharotics 

in,    277-2S6 
chian      turpentine      in, 

257,    258 
Davis  "cancer  cure"  in, 

271-275 
"destructive        fulgura- 

tion"    in,    310 
diathermy      or      trans- 
tbermy (Nagel- 
schmidt)     in,    320, 
321 
distinguished    from    in- 
vestigation,   35 
Doven's  vaccine  in,  256, 

257 
electricity  in,   289-296 
electrocautery  in,   306 
electro  coagulation 
(Doyen)     in,     321, 
322.    326 
fluorescent    stimulation 

in,   291 
fulguratinn     (de    Keat- 
ing-Hart)   in.    310- 
316.    325,    320 
heat   in.    287,    288 
bigh-frequency    current 


(Bvrne        method)  ' 
in,    308,    309 

in  inoperable,  irre- 
movable, incurable 
cases,   422-428 

incandescent  light  in, 
290,   291 

ionic  surgery  in,  323, 
324 

Mattel  "electricities" 
in,  201-268 

mesothorium  in,  304, 
305,   325 

molasses  in,  259 

non-surgical,  277-344 

opotherapeutic  meas- 
ures  in,   343 

oscillatory  desiccation 
(Clark)  in,  322, 
323 

palliative  measures  for, 
369-414 

physiotherapy  in.  287- 
326 

plastic  procedures  in, 
368.  369 

quack  cures  in,  261-276 

queer  ideas  of  ancients 
concerning,  2 

radio-active   gelatin  in, 

305,  306 
radio-activity    in,    297- 

306,  325 
radium  in,  297-304.  325 
residues,    extracts    and 

emulsions  in,    338- 
341 
sera  in,   332-338 
serum     from    birds    of 

prey    in,    251 
serous  '  exudates     and 
bodv       fluids       in, 
341-343 
sunlight  in,  288.  289 
sodium   oleate   and    ox- 
gall in,  258,  259 
surgical,    345-414.      See 
also      Surgical 
treatment, 
thermopenetration     (d'- 
Arsonval)    in,   316, 
317 
thermoradiotherapy  (de 
Keating-Hart)     in, 
317-320,   320 
vaccines   in,    338-343 
violet    leaves    in,    200, 

201 
X-ravs     in.     291,     296, 
324.  325 
Treatment  of  cancer,  per 

se,  422 
Treatment    of    conditions 
caused  by  or   com- 
plicating      cancer, 
421,    422 
Treatment      of      patient, 

422 
Trees,   tumors  of,   40,   46. 
See     also     Crown- 
galls. 
Tropics,    cancer   in,    62 
Trout,    cancer   in,    56,    57 
Trypsin,   331 

effects   of  use  of,    249, 
250 
"Trypsin   abscess,"  249 
Trypsin  test.  30.    See  aUo 
Enzyme    treatment 
Tubercle,     tumors      in 
birds  due  to,  54 


Tuberculosis  and  cam- 
paign of  education, 
4 

Tuberculosis,   cancer  and, 
118 
of  kidney,  mistaken  for 

cancer,    205-207 
predisposing  to   cancer, 
224 

Tuberculosis,       treatment 
of,       with       meso- 
thorium.  304 
with    thorium    X,    304 

Tuberculous  abscess,  mis- 
taken for  sarcoma, 
203 

Tuberculous  sinus  of  the 
breast  diagnosed 
as   cancer,    444 

Tumor  cells,  constancy 
and  variability  of, 
162 

"Tumor  germs"  in  the 
body,  44 

Tumor  strands,  42.  43 

Tumor    toxins,    249 

Turkey,  attitude  toward 
cancer  conferences, 
11 

Twig  galls,   43 

Udder,  cancer  of,  in  cow, 

52 
Ulcer,     cancer     suspected 
from,  188 
in   early    stage   of   can- 
cer,   181,    182 
Ulcer,    indolent,    small 
doses   of   X-ray   in 
treatment    of, 
294 
malignant,  sunligh.t 
treatment  for.   289 
on    eyelid,    epithelioma 
following,  230 
precancerous,  use  of  alum 
for,    279 
use  of  silver  nitrate 
for,   279 
rodent,  effect  of  radium 
treatment   on, 
303 
Ulcerated      cancer,      pre- 
operative   treat- 
ment    of,    350 
Ulcerating  neoplasms,  ef- 
fects of  radium  on, 
298 
Ulcerating     surfaces,     in 
cancer,      care      of, 
427,   428 
Ulceration,    186 
United       States,       cancer 
statistics     in,     74, 
102 
death    and   birth    regis- 
tration   in.    75 
United   States   Fish   Com- 
mission  on   cancer 
in  fish,   56 
Universality     of     cancer, 
60-69 
Gilbert   Islands,    68 
Iceland,  68,   69 
India,    66-68 
statistics  showing.   72 
University      of      Buffalo, 

5,    6 
Ureters,   avoidance  of  in- 
jury to,  in  arterial 
ligation,  390 


INDEX 


533 


Ufcters,      cathotcri^^ation 
of,    iji'uliniiuar.v   to 
operation    for 
cancer    of    uterus, 
353 
cicatricial    contractions 
causing       pressure 
on,  394 
closure    of,     by    malig- 
nant   growth,     ne- 
phrotomy   in,    413 
Ureteral    transplantation, 

413,  414 
Urethra,    cancer    of,    cys- 
tostomy   of,    413 
death      rates      from, 
78 
Urinary     calculi,     predis- 
posing   to    cancer, 
127 
Urinary     system,     pallia- 
tive   measures    ap- 
plied  to,    413,    414 
Urine,    effect    of    trypsin 
on,    250 
examination       of,       in 
diagnosis    of    can- 
cer,  191,   192 
study    of,    31 
Uterine  arteries,    ligation 
of,    383,    384,    385. 
3S6,    391,    392 
Uterine  cancer,  rarity  of, 

in  dogs,   51 
Uterine    fibroid    mistaken 

for  cancer,  216 
Uterine    fibroids,    compli- 
cating    cancer     of 
the  breast,  419 
Uterine  polypus  mistaken 

for  cancer,   216 
Utero-ovarian  arteries,  li- 
gation of,  385 
Uterus,    cancer   of,   319 
arterial     ligation     in 
treatment    of,    308 
cases  of,  in  Tarawa, 

68 
death    rates    for,    78, 

79,  86 

catheterization        o  f 

ureters  previous  to 

operations  for,  353 

chian    turpentine    in 

treatment   of,   258 

e  1  e  c  t  r  ocauterization 

in     treatment     of, 

306 

electrocoagulation   in 

treatment    of,    322 

ligation     of     arteries 

in,  383 
use      of      starvation 
ligature     in,     383, 
384 
Wertheim   method  of 
treatment  for,  308 
carcinoma      of,      meso- 
thorium   treatment 
for,   305 
radium    treatment 

for,  299,  305 

with  myoma,  radium 

treatment  for,  302 

malignant    growths    of. 

radium     treatment 

of,  298 

polypoid     growths     of, 

136 
tumor  of,   thermoradio- 
therapy in,  316 


Utility  of  combining  clin- 
ical and  experi- 
mental work,  32 

Vaccination,   definition  of, 

329,    330 
Vaccine    emulsion,    Cocu- 

Gilman,    328 
Vaccines,      definition     of, 
329,    330 
Doyen's,    256,    257 
Doyen's        Micrococcus 

neo  for  mans,  330 
examples   of,    330 
in  treatment  of  cancer, 

327,    338-343 
Jacob    and    Geets'    bac- 
terial,  330 
Schmidt's,   252-256 
use    of  term,    328 
Van    Niekerk,    Mrs.,    270, 

271 
Variability  of  histological 
sti'uctures,      16  2, 
163 
of     power     to     develop 
sarcoma.    164.    165 
of  tumor  cells,   162 
Vascular    system,    pallia- 
tive    measures     in 
cancer   applied   to, 
372-411. 
Vaughan      residue,      330, 

339,   340 
Vegetable  caustics,  285 
Vegetable  tumors,  37,  40- 
46 
analogy  of  animal  and 
human       tumors 
with,   43,   44,   45 
causes  of,  41 
due     to     extrinsic 

causes,   40,  41 
due  to  intrinsic  causes, 

45 
theories  of,  43 
Vegetable      tumors,       va- 
rieties of,  40 
Vegetables,  use  of,  in  re- 
lation    to     cancer, 
82 
Veins,    spread    of    cancer 
cells  through,  140, 
141 
Ventilation.       importance 
of,  in  treatment  of 
incurable      cancer, 
426 
Vienna     paste    in     treat- 
ment    of      cancer, 
285 
Vienna,   relation  of  over- 
crowding   to     can- 
cer in,  93 
Violet     leaves     in     treat- 
ment    of      cancer, 
260,  261 
Virchow's  theory  of  can- 
cer causation,   111 
Visceral    tumors,    radium 
treatment  for,  300 
Vital     statistics     in     the 
United    States,    75. 
See  also  Statistics. 
Volvulus,     correction     of, 
arterial        ligation 
and,  389,   392 
Vomiting     in     brain     tu- 
mors,  relief  of,   by 
decompression    op- 
eration,   369 


Vulva,  epitheliomata  of, 
radium  treatment 
of,  302 

Waldeyer'.s  theory  of  can- 
cer causation,  112, 
113 

Wales,  cancer  death  rate 
in,   73 

Warts,  malignant  di'- 
generation  of,  81', 
223 

Water,  influence  of,  in 
goiter    in    fish,    58 

Weights  of  organs  in 
cases  of  tumor, 
173,    174 

Whitehead's  shellac,  428 

Wild  animals,  cancer  in, 
52-54 

Wild  birds,  malignant  tu- 
mors in.  54 

"Witch    doctor,"    2 

"Witches'   broom."   41 

"Witches'    broth,"    2 

Whitbread,  founder  of 
cancer  department, 
Middlesex  Hospi- 
tal, 13,  15 

Wlaeff's  serum,  329,  332, 
333 

Workmen's  Compensation 
Act  and  cancer, 
128 

Wyeth's  toxins,   329,   333 

Xeroderma    pigmentosum, 

precancerous,   222 
X-ray  dermatitis,   precan- 
cerous, 222 
X-r-ny    treatment    of   ade- 
nomatous     a  r  m, 
324 

analgesic  effect  of,  324 

of  cancer  of  breast, 
296 

of  epithelioma  of  skin. 
285 
X-ray   tube,    294 
X-ray  ulceration  in  rats. 

293 
X-rays  as  cause  of  cu- 
taneous cancer, 
292 
X-rays,  experimental  pro- 
duction of  cancer 
after  exposure  to, 
160 

effect  of,  upon  warmed 
cells,  320 

experiments  with,  upon 
plants,  294 

exposure  of  healthy  tis- 
sue to,  results  of, 
293 

exposure  of  rats  to, 
results  of,  292, 
293 

in  thermoradiotherapy, 
317,    320 

in  treatment  of  cancer. 
291-296,  297,  319. 
416 

large  doses  of,  effects 
of.   294 

prophylactic  use  of. 
362 

small  doses  of  effects 
of,  294 

Yeast   poultices,   427 


)34 


INDEX 


Zinc   chlorid,   2S3,    284 

Bougards  paste  of,  in 
cauterization  o  f 
cancer,    2S3 

Canquoiu's  paste  of,  in 
cauterization  o  f 
cancer,    2^3 

"Dr.  Fell  treatment" 
with,  in  cauteri- 
zation of.  cancer, 
283 

5  per  cent,  solution  for 
parenctiymatous  in- 
jection.   2S4 

in  treatment  of  cancer, 
2.S3,    393 
Zinc    oxid    ointment,    use 


of,    following    can- 
cer  operation,   353 
Zinc  chlorid  paste,  427 
Zinc    sulphate    in    treat- 
ment    of     cancer, 
285 
Zoological       distribution, 
47-59 

age    incidence    in,    49, 
50 

in  bovines,  52 

in  cats,  51 

in  dogs,  50,  51 

in    domesticated    fowl, 
54 

in  fish,  55-58 

in    horses,    51-53 


Zoological  distribution,  in 
moUusks,    5S,    59 

in  reptiles  and  am- 
phibians, 54 

in  swine,  sheep,  and 
goats,   52 

in  wild  animals  in 
their  native  state 
and  in  captivity, 
52-54 

in    wild    birds,    54 

influence  of  environ- 
mental changes  in. 
including    diet.    47 

influence  of  heredity 
in,   48,    49 

site  incidence  in,  50 


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'T^HE  following  pages  contain  advertisements  of 
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New  Works  on  MEDICINE,  SURGERY  and  ALLIED  SUBJECTS 

Infection  and  Resistance 

By 
Dr.  Hans  Zinsser 

Professor  of  Bacteriology,  Columbia  University 

Students  and  physicians  who  have  considered  immunity,  and  the  forces 
of  resistance  to  infectious  diseases  in  the  human  body,  as  subjects 
which,  on  account  of  their  technical  treatment,  should  be  relegated 
to  the  laboratory  specialist,  will  heartily  welcome  the  publication  of 
Infection  and  Resistance  by  Dr.  Hans  Zinsser,  Professor  of  Bacteri- 
ology at  Columbia  University.  The  increasing  eagerness  of  the 
medical  profession  to  obtain  a  knowledge  of  immunity  has  caused 
the  publishers  to  persuade  Dr.  Zinsser  to  embody  in  text-book  form 
his  experience  in  presenting  this  subject  to  students  with  clearness 
and  simplicity. 

The  plan  followed  in  the  presentation  will  appeal  particularly  to  under- 
graduates. The  material  dealt  with  is  fundamental  to  the  compre- 
hension of  the  processes  involved  in  the  occurrence  and  cure  of 
infectious  diseases  and  a  thorough  study  of  its  facts  and  theories  is 
almost  necessary  as  a  preparation  for  the  study  of  infectious  disease 
in  the  clinic.  Reference  to  the  clinical  application  of  facts  and 
theories  is  made  wherever  feasible.  The  subject  is  such  that,  how- 
ever remote  from  the  practical  many  of  its  phases  may  seem,  in- 
ferences from  laboratory  to  bedside  are  often  possible.  The  book, 
in  other  words,  is  written  for  medical  men  primarily.  Detailed 
instructions  for  laboratory  methods,  where  given,  are  illustrative 
of  the  justification  for  conclusions  reached  by  experiment. 
The  chapter  on  Colloids,  by  Professor  Stewart  Young,  of  Stanford  Uni- 
versity, is  written  as  a  separate  unit  so  that  the  frequent  allusions 
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New  Works  on  MEDICINE,  SURGERY  and  ALLIED  SUBJECTS 

On  Diseases  of  the  Rectum  and  Anus 

By  Harrison  Cripps,  F.R.C.S.,  Consulting  Surgeon,  St. 
Bartholomew's  Hospital.  Fourth  Edition,  including  the 
Sixth  Edition  of  the  Jacksonian  Prize  Essay  on  Cancer, 
and  the  Opening  Address  on  the  Surgical  Treatment 
of  Rectal  Cancer,  delivered  at  the  Annual  Meeting  of 
the  British  Medical  Association,  Liverpool,  191 2. 
Illustrated.    Cloth,  8vo,  $3.25 

Dr.  Cripps,  the  author  of  this  important  monograph,  Is  well  known  in 
this  country  as  an  authority  on  these  subjects  and  as  a  wide  con- 
tributor to  many  American  medical  magazines.  The  clinical  cases 
recorded  in  this  monograph  are  largely  drawn  from  his  notes  made 
in  the  Registers  of  St.  Bartholomew's  Hospital,  and  the  pathologi- 
cal observations  have  been  verified  by  post-mortem  or  microscopic 
investigation. 

Anesthetics  and  their  Administration 

A  Text-Book  for  Medical  and  Dental  Practitioners 
and  Students 

By  Sir  Frederic  Hewitt,  M.V.O.,  M.A.,  M.D.,  Cantab., 
Anesthetist  to  His  Majesty  the  King,  Physician-Anes- 
thetist to  St.  George's  Hospital,  Consulting  Anesthetist 
to  the  London  Hospital,  Late  Anesthetist  to  the  Charing 
Cross  and  Royal  Dental  Hospitals  of  London.  Fourth 
Edition,  prepared  with  the  assistance  of  Henry  Robin- 
son, M.A.,  M.D.,  B.C.,  Cantab.,  Anesthetist  to  the 
Royal  Samaritan  and  Cancer  Hospitals. 
Octavo,  676  pages,  with  71  Illustrations.    Price  $5.00 

"Dr.  Hewitt's  work  ....  contains  practically  everything  of  value 
on  the  subject  which  would  be  of  service  to  the  student  or  practi- 
tioner. " — Medical  Record. 

"Every  hospital  interne  will  be  the  better  for  it  if  he  earnestly  studies 
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ist." — American  Journal  of  Surgery. 

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New  Works  on  MEDICINE,  SURGERY  and  ALLIED  SUBJECTS 

Researches  on  Rheumatism 

By 

F.  J.  Poynton,  M.D. 

London,  Vice-Dean  of  University  College  Hospital  Medical  School, 
Senior  Physician  to  Cut-patients  atj  University  College  Hospi- 
tal, London,  etc.,  and   Alexander  Paine,  M.D.,  London, 
D.P.H.  England,  Director  of  the  Cancer  Research 
Institute,  London. 

461  pp.,  index,  with  frontispiece  in  color  attd  106  ill.,  8vo,  $5.00 

This  collection  of  papers  is  the  result  of  fifteen  years'  work  by  these  two 
noted  authorities,  who  are  well  known  to  the  American  profession 
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recent  and  authentic  presentation  of  a  very  important  group  of 
diseases  and  at  the  conclusion  of  the  volume  the  bearing  of  these 
investigations  upon  clinical  medicine  and  public  health  is  considered 
in  a  special  article.  Etiology,  pathology,  symptomology,  diagnosis, 
prognosis,  treatment  and  prevention  are  summarized  at  the  end, 
so  that  this  work  stands  as  a  complete  treatise  on  the  subject. 
The  illustrations  have  been  chosen  with  the  intention  of  demonstrat- 
ing the  intimate  processes  of  rheumatism  in  the  body,  and  to  act 
as  a  pictorial  guide  to  the  main  conclusions.  Their  workmanship 
is  so  perfect  that  they  are  almost  equal  to  the  microscopic  slide 
itself. 

"The  papers  are  for  the  most  part  arranged  in  chronological  order,  and 
taken  together  form  a  consistent  account  of  a  very  protracted 
research  which  has  acquired  a  special  value  as  the  joint  work  of 
clinicians  and  bacteriologists.  .  .  The  record  of  work  that  they  have 
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New  Works  on  MEDICINE,  SURGERY  and  ALLIED  SUBJECTS 

Diseases  of  the  Liver,  Gail-Bladder  and 
Bile  Ducts 

By  Humphry  Davy  Rolleston,  M.A.,  M.D.,  F.R.C.P.,  Senior  Physi- 
cian, St.  George's  Hospital;   Physician  Victoria   Hospital  for 
Children,  Chelsea  ;    formerly  Fellow  of  St.  John's  College, 
Cambridge.     Second  Edition. 

Illustrated.     Svo,  Sii  pp.,  $7.00 

The  work  has  been  thoroughly  revised ;  much  new  matter  has  been  added, 
many  alterations  have  been  made,  and  condensation  has  been 
carried  out  as  far  as  is  compatible  with  a  full  consideration  of  the 
subject. 

During  the  past  twelve  years  Dr.  Rolleston  has  paid  special  attention  to 
diseases  of  the  liver,  both  from  the  clinical  and  pathological  points 
of  view.  In  the  description  of  each  disease  attention  is  first  directed 
to  the  underlying  morbid  changes,  as  without  a  grasp  of  these  it 
is  impossible  to  make  a  rational  diagnosis,  to  treat  the  clinical  mani- 
festations in  a  satisfactory  manner,  or  to  give  a  reliable  prognosis. 
Selected  cases  at  St.  George's  Hospital,  London,  have  been  embodied 
in  the  text,  especially  in  the  parts  dealing  with  the  sjTnptoms  and 
clinical  aspects.  The  illustrations  are  nearly  all  original  and  have 
been  carefully  selected. 

Lectures  on  the  Nervous  and  Chemical  Regu- 
lators of  Metabolism 

By  D.  Noel  Payton,  M.D.,  B.Sc,  Professor  of  Physiology  in  the 
University  of  Glasgow. 

Cloth,  217  pp.,  hibliog.,  Svo,  $2.00 

The  majority  of  books  thus  far  published  on  the  action  of  the  ductless 
glands  are  so  technical,  elaborate  and  large,  that  they  are  obsolete 
before  they  can  be  thoroughly  studied  by  the  average  practitioner. 
Particularly  timely,  therefore,  is  this  monograph,  which  presents  the 
subject  in  a  brief  and  comprehensive  manner  well  summarized  and 
not  too  technical.  Three  factors  are  chiefly  considered:  (i)  Hered- 
ity Inerita  of  Inherited  Developmental  Tendencies;  (2)  The  Nervous 
System;  (3)  The  Chemical  Products  of  Various  Organs,  the  so-called 
Internal  Secretions. 

It  is  needless  to  say  that  the  standing  of  the  author  guarantees  the 
authenticity  of  view  and  correctness  of  judgment  displayed  in  the 
preparation  of  the  book. 


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New  Works  on  MEDICINE,  SURGERY  and  ALLIED  SUBJECTS 

Cancer 

Its  Cause  and  Treatment  Without  Operation 

By 

Robert  Bell,  M.D.,  F.R.F.P.S.,  etc. 

Late  Consulting  Physician  to  the  Glasgow  Hospital  for  Women; 

Physician  in  Charge  of  Cancer  Research,  Battersea  Hospital; 

Author  of  "  Health  At  Its  Best  Versus  Cancer,"  "  Women 

in  Health  and  Sickness,"  etc. 

Second  Edition,  Revised.    Cloth,  i2mo,  $1.75 

Dr.  Bell  has  given  in  this  book  a  popular  but  complete  account  of  the 
disease  of  Cancer,  the  various  attempts  which  have  been  made  to 
meet  it,  and  the  success  of  his  own  treatment  without  operation. 

The  Stomach  and  Elsophagus 

A  Radiographic  Study 

By  Alfred  E.  Babclay,  M.A.,  M.D.,  B.C.  (Cantab.),  M.R.C.S., 
L.R.C.P.,  Medical  Officer  to  the  X-Ray  and  Electrical  Depart- 
ments of  the  Manchester  Royal  Infirmary,  etc.     With 
29  radiograms  and  diagrams. 

Cloth,  8vo.    $3.00 

The  difficulties  and  intricacies  of  the  diagnosis  of  intra-abdominal  lesions, 
even  in  experienced  hands,  is  so  great  that  the  importance  of  any 
new  method  that  will  be  of  assistance  in  the  diagnosis  of  these  cases 
cannot  be  overestimated. 

This  work  is  published  at  the  special  suggestion  of  Sir  William 
Osier,  Sir  Clifford  Allbutt  and  Dr.  R.  Hutchinson.  In  it  the  author 
deals  chiefly  with  the  explanation  of  the  various  diffiuclties  met  with 
in  the  normal  and  pathological  cases  examined,  and  lays  down  the 
signs  on  which  the  diagnosis  of  morbid  conditions  may  be  given. 


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